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Open Hearts, Open Gates‌.

Printed by: Print World # 9810185402

Comprehensive Care for Street Children: Handbook for Planners and Practitioners Physical Health Care

Indradhanush Academy Centre for Equity Studies 105/6A, 1st Floor, Adhchini, Aurobindo Marg, New Delhi-110017 Ph.: 011-26514688, 41078058 Email: indradhanush.ces@gmail.com Website: centreforequitystudies.com

Centre for Equity Studies

Indradhanush Academy Centre For Equity Studies

Indradhanush Academy


la?k"kZ dh jkgksa esa la?k"kZ dh jkgksa esa] dksbZ rks gekjk gks---gj jkr dh ckgksa esa] lqcg dk ut+kjk gks

In this life full of strife In this life, full of strife, We long for a friend and guide... In the darkness of night We long for a dawn, warm and bright

la?k"kZ dh jkgksa esa] dksbZ rks gekjk gks---geus rks t+ekus dh] jaft'k dks gh ih Mkyk pqHkrs gq, gj iy dks] gl [ksy ds th Mkyk

In this life full of strife, We long for a friend and guide… We swallow hatred and the vile Stinging moments, with a smile

D;ksa iwN jgs gks rqe] D;k geus xok;k gS thou dh rks cl NksM+ks] gj [okc ijk;k gS

Why do you ask, what have we lost, Not just life, even our dreams went past...

la?k"kZ dh jkgksa esa] dksbZ rks gekjk gks----

In this life, full of strife We long for a friend and guide…

oks iy Hkh Fkk viuk] ;s iy Hkh gekjk gS la?k"kZ dh jkgksa esa] vc dksbZ gekjk gS---oks jkrsa feV gh xbZ] ,d lqcg vkbZ u;h py jgs veu dh jkgksa ij] gj [okc gekjk gS ,d vk'kk veu dh] gS vc bl fny esa dksbZ jkg u vc jksds] dqN dj ds fn[kkuk gS c<+k,axs ge dne dks] feVk;saxs gj xae dks pysaxs mu jkgksa ij] tgk¡ ls fn[krk fdukjk gS la?k"kZ dh jkgksa esa] gj dksbZ gekjk gS----

In this life, full of strife, We have someone as a guide and friend…

List of Team Members who Authored the Manuals Ambika Kapoor Anant Asthana Deepika Nair Dr. Madhurima Nundy Dr. Vandana Prasad Harsh Mander Harshdeep Singh Preeti Mathew Rachel Firestone Saheli Bhattacharya

That past was ours, this present is ours In this life, full of strife, Now we have someone as a guide and friend…

Satya Pillai

Those nights have passed, there dawns a new sun Walking on the paths of peace, every dream is ours

Sharmila Sinha

There is a ray of hope in this heart There is no stopping us; we have to achieve something now We will take a step forward, remove all the pain We will walk on paths in life, from where the shore is near In this life, full of strife, We have everyone as a guide and friend…

Written by one of the child from Sneh Ghars in Delhi

Shaheen Adreshir

Shashi Mendiratta Subroto Baul Sunil Snehi Sveta Dave Chakravarty


Open Hearts, Open Gates…”

Comprehensive Care for Street Children: Handbook for Planners and Practitioners Physical Health Care

Indradhanush Academy Centre for Equity Studies


We would like to thankâ&#x20AC;Ś In researching and writing these handbooks, we have drawn on best examples in the work by pioneers like Sister Cyril in Kolkata, MV Foundation led by Shantha Sinha and the BOSCO Brothers. We have added learning based on the efforts of Centre for Equity Studies and Aman Biradari, of work with state governments of Andhra Pradesh and Delhi; to establish and manage Sneh Ghars in Hyderabad and Delhi. Without the support of the senior officials in the Department of School Education, Ministry of Human Resource Development (MHRD) especially Secretary, Anshu Vaish, Additional Secretary Anita Kaul, Directors Neelam Rao and Maninder Kaur, and the state governments of Andhra Pradesh and Delhi, this effort would not have been possible. This first volume is a summary of all the detailed Handbooks, giving a brief overview of the steps required to reach street children, and ensure their access to rights to protection, food, education and health care. We hope it will be useful for both policy makers and practitioners. This effort was supported by grants from ICCO & Kerk in Actie; and Axis Bank for which we are very grateful, and look forward to further support for this work from diverse sources, including Save the Children, Partnership Foundation and Sir Dorabji Tata Trust. We are grateful to the following experts who authored various portions of the detailed manuals; for each, this was a labor of love. The writers are Ambika Kapoor, Anant Asthana, Deepika Nair, Dr. Madhurima Nundy, Dr. Vandana Prasad, Harsh Mander, Harshdeep Singh, Preeti Mathew, Rachel Firestone, Satya Pillai, Shaheen Adreshir, Sharmila Sinha, Shashi Mendiratta, Subroto Baul, Sunil Snehi and Sveta Dave Chakravarty. We thank Father Koshy of Navjeevana Bala Bhavan, Vijayawada (Andhra Pradesh), Father George of Bangalore Oniyavara Seva Coota (BOSCO), Bangalore (Karnataka) for giving their valuable time and sharing their experiences. We thank Aisha Khan from Hamdard Girls Hostel, Dr. Sushma Goel, Lady Irwin College and Dr. Neerja Jaiswal, MS University, Baroda for giving us technical expertise on Home Management. Special thanks to Dimple Mander, who gave her valuable time and insights. We are grateful to Salaam Balak Trust and Karam Marg, for allowing us to visit their homes and understand different perspectives of care and documentation. We thank Dayaram, Annie Koshy, Anita Rampal, Dilip Ranjekar, for taking time to review and provide valuable feedback, suggestions and inputs for the education component. We are grateful to Dr. K.R. Antony, Pediatrician and President, Public Health Resource Society (PHRS); Prof. Rama V. Baru, Professor, Centre of Social Medicine and Community Health (CSMCH), Jawaharlal Nehru University (JNU); Mita Deshpande, Research Scholar, CSMCH, JNU; Arun Srivastava, Consultant, National Health Systems Resource Centre (NHSRC); Dr. Lipi Dhar, HOPE Project; and Ifat Hamid, ARK Foundation who reviewed the Health Manual and gave valuable inputs. We are grateful to Dr. Shanti Raman, Community Pediatrician, South West Sydney and Sydney Local Health Networks for providing background material 3


and reviewing the module; Dr. Ramani from Jan Swasthya Sahyog (JSS) for providing the JSS Drug formulary; Ms. Mridula Bajaj and Ms. Kamini Malhotra from Mobile Crèches for accessing their health record formats; Ms. Mita Deshpande for First-Aid information and booklet developed under the School Health Project of University School Resource Network (USRN) and Dr. Ganpathy, PHRN. We learnt a great deal from the children themselves, as well as the team members or Sneh Sathis who undertook the pilot to establish Sneh Ghars, in Loreto Rainbow Home, Kolkata, the Dilse team, Delhi, and the Aman Vedika team, Hyderabad, for providing rich insights on residential care setups in functional schools. We acknowledge Satyaâ&#x20AC;&#x2122;s stewardships and for holding the reins of all the teams to ensure timely completion of this complex task. She was ably advised by Sister Cyril, Sveta Dave, K Anuradha, Ferdinand Van Koolwijk, Fr George Kollashany, and Shashi Mendiratta; and assisted by her team members Preeti Mathew and Ambika Kapoor. Finally, sincere and heartfelt thanks to Harsh Mander, for his inspiring leadership of the entire process of putting our learnings together and ensuring that the child remained in focus at all times.

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Contents Section I Introduction................................................................................................................. 7 Chapter1: Health needs and rights of street children................................................................ 9 Chapter 2: Health Standards for Residential Care: Global Perspective..............................11 Chapter 3: Approaches in Long term Residential Care...........................................................15 Chapter 4: Ethical issues in Health in long term Residential Care..........................................19 Chapter 5: Principle Processes of Health Care..........................................................................21

Section II Health systems at the Home..................................................................................26 Chapter 6: Preventive and Promotive Health Programs..........................................................27

Food and Nutrition.....................................................................................................27

Infrastructure and Hygiene in the Homes..............................................................31

Growth Monitoring....................................................................................................31

Health Education and Health Camps.....................................................................35

Chapter 7: Curative Health Program...........................................................................................37

First Aid Program.......................................................................................................37

Common Childhood Illnesses....................................................................................37

Chapter 8: Drug Formulary...........................................................................................................55 Chapter 9: Human resource: Structure, Roles, Responsibilities and Monitoring mechanisms.............................................................................................60 Chapter 10: Training and Capacity Building.............................................................................65 Chapter 11: Maintenance of Health Records and Documentation.........................................70

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Annexures Annexure 1 (i) - Health Assessment Form of a Child...........................................74

Annexure 1 (ii) â&#x20AC;&#x201C; Yearly Health Plan of a Child..................................................86

Annexure 1 (iii) Format of Monthly Report...........................................................89

Annexure 2 (i) Drug Formulary by Jan Swasthya Sahyog..................................90

Annexure 2 (ii) Intravenous Medications by Jan Swasthya Sahyog..................96

Annexure 2 (iii) Locost Drug Price List................................................................. 103

Annexure 3: z score Charts for Growth Monitoring......................................... 107

Bibliography................................................................................................................................. 113 Abbreviation................................................................................................................................. 116

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Section

I

Introduction

Street Children: Health In India, people on the city streets are invisible to public policy though they are visible daily to policy makers as they drive through the same city streets. People on the street occupy cities virtually as non-citizens and therefore face issues of identity. Amongst the homeless, children are the most marginalised and vulnerable. In India, they are categorised as children in difficult circumstances along with other children who do not have parents, are in bondage, are victims of trafficking, are affected by terminal diseases or HIV/AIDS, children in conflict areas or those affected by natural disasters, etc. There is a clustering of disadvantages for street children that make them more vulnerable. These are linked to their socio-economic conditions and the life events and experiences they come from. They may even have been victims of varying degrees of violence and abuse. Children living on the streets may be either living with parents who are homeless or they may have no parents at all. They may also have escaped on the streets from abusive, violent, alcoholic parents or parents who are unable to take care of them. Children on the streets experience hunger and morbidities in everyday living. Trauma is part of their daily lives. They find various coping strategies for survival by forming peer groups, finding work or other ways to earn money, early initiation into sexual activities, prostitution and use of soft drugs. These have implications for chronic physical and mental health problems both early and later in life. The availability of food to children living on the streets is mixed. The quantities may be (but are not always) sufficient. The quality however uniformly tends to be monotonous, elementary, often of poor nutritional value and (in the nature of their existence) unhygienic. It is indeed the search of food, which has led many to the streets. Sufficiency of food seems far more important to the homeless than its nutritional content. Except those with families in the streets, children rarely get home cooked food. Many buy cooked food, sometimes from humble eateries on the pavements themselves. Special health needs of street children Homelessness has been found to be a significant predictor of poor health status all over the world. Studies in the context of United States show that children on the streets have a higher incidence of trauma-related injuries, developmental delays, sinusitis, anaemia, asthma, bowel dysfunction, eczema, visual and neurological deficits as well as other disabilities. Hunger and malnutrition is very common among children on the streets. These children are not only underweight, but their growth has often been stunted. Furthermore, runaway youth or young people living on the streets are at significant risk of violence and victimisation, 7


substance abuse, pregnancy, and sexually transmitted diseases. Many children may be living with families affected by drugs, alcohol and domestic violence. Evidence from studies suggests lack of appropriate care for known acute/chronic health conditions, and failure to diagnose health and mental health problems.1 They do not have access to comprehensive health services, immunisations, routine child health surveillance and health promotion. Studies on street children in India show that the children experience high rates of physical, emotional and mental health problems. They are susceptible to cuts, injuries, animal bites, skin infections, fevers, tuberculosis and respiratory problems. Many also suffer from chronic health problems. Their intake of food is inadequate and the quality of food is poor and hence there are many malnourished children. There are many cases of children with sexually transmitted infections (STIs). In India there are very few studies available on the mental status of children on the streets but it is a known fact that mental and emotional health problems are prevalent amongst the children. Depression, anxiety and low self-esteem are very common.2 According to a recent study by Save the Children on street children in Delhi, it was observed that street children had limited access to health services and these were mostly provided by NGOs or mobile clinics run by NGOs. Health camps were also seen as the most popular source of treatment. Government services did not reach these children.3

Committee on Community Health Services (2005), Providing Care for Immigrant, Homeless and Migrant Children, in American Academy of Pediatrics, Vol. 115, No. 4, pp. 1095-1100

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SNEHA (2008), Making Health Care Accessible to Street Children: The â&#x20AC;&#x2DC;Hospital on Wheelsâ&#x20AC;&#x2122; Project (2000- 2006), Sneha: Mumbai.

2

Save the Children (2011)

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Chapter

1

Health Needs and Rights of Street Children

Declaration on Child Rights There are two levels to addressing health needs of street children – the first is at the broader level of addressing the health needs and rights of ALL children in general. However, it is also important to plan for the specific health needs of children living on the streets and living in residential institutions. India is a signatory to The United Nations Convention on the Rights of the Child. Specific articles in the Convention that are relevant to the health of a child are listed below. Articles 24, 25 and 39 are significant for their relevance and importance for the health rights of children on the street (see Box 1). Box 1: United Nations Convention on the Rights of the Child

• Article 23: A mentally or physically disabled child should enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance and facilitate the child’s active participation in the community;

• Article 24: The right of any child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health;

• Article 25: The right of a child placed by competent authorities for the purposes of care, protection or treatment of his or her physical or mental health, to a periodic review of the treatment provided to the child and all other circumstances relevant to his or her placement;

• Article 39: All appropriate measures to be taken to promote the physical and psychological recovery and social reintegration of a child victim of any form of abuse and neglect. Source: United Nations Convention on the Rights of the Child (1989)

The Constitution of India recognises the vulnerable position of children and their right to protection. In Article 15, the Constitution guarantees special attention to children through necessary and special laws and policies that safeguard their rights. The Right to Equality, Protection of Life and Personal Liberty and the Right against Exploitation is enshrined in Articles 14, 15, 16, 17, 21, 23 and 24. One of the Directive Principles of State Policy in India states that the State shall endeavour to achieve social and economic welfare of the people by: ‘guarding the children against exploitation and moral degradation’. In India, the National Commission for Protection of Child Rights (NCPCR) was set up in March 2007 under the Commission for Protection of Child Rights Act, 2005, by an act of Parliament (December 2005). The Commission's mandate was to ensure that all laws, 9


policies, programmes, and administrative mechanisms are in consonance with the Child Rights perspective as enshrined in the Constitution of India and also in the UN Convention on the Rights of the Child. The Integrated Child Protection Scheme (ICPS) came into effect from 2009 and is a comprehensive, centrally sponsored scheme introduced by the Ministry of Women and Child Development, Government of India, to provide a safe and secure environment for children so that they do not become vulnerable to exploitation, neglect and abuse. The spirit of all the declarations goes beyond the physical health of a child and talks of his/her overall well-being. The concept of well-being is very important in a programme for child health. The international classification of Functioning, Disability and Health defines well-being as follows: ‘Well-being is a general term encompassing the total universe of human life domains including physical, mental and social aspects, that make up what can be called a “good life”. Health domains are a subset of domains that make up the total universe of human life’.4 Therefore, children and young people need to develop healthy lifestyles and opportunities to achieve optimum health and well-being. This is not an individual responsibility but a collective responsibility of institutions and society that help children and young people to develop resilience, capacity and emotional well-being to allow them to play, learn and relate to other people. To achieve these there needs to be a secure and enabling environment where children and adolescents have access to health services that secures their mental and physical well-being. It should also allow opportunities for participation and take effective action that gives them a sense of worth in life.

Department of Health (2002), Promoting the Health of Looked After Children, London: Department of Health Publications

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Chapter

2

Health Standards for Residential Care: Global Perspective

There are no documented protocols on health standards for children in India but there is material available on child health standards in other countries such as Australia (see Box 2) and the United Kingdom (see Boxes 3&4). These are not specific to street children but for out-of-home care for children and looked-after children. Unlike India, they have regulations for the care of children; for example, the Care Standards Act 2000 in UK outlines responsibilities of agencies and carers in promoting health of children who are looked after. The guidance provided under these Acts is in accordance to the UN Convention on the Rights of the Child. Box 2: Excerpts from National Standards of Out-of-Home Care for Children in Australia Australia has outlined National Standards of Out-of-Home Care for Children. The following excerpts are taken from their module and are specific to those that address health needs of out-of-home care for children. Standard 4: Each child and young person has an individualised plan that details their health, education and other needs. Standard 5: Children and young people have their physical, developmental, psycho-social and mental health needs assessed and attended to in a timely way. What this means Children and young people entering care are to have their health needs assessed and receive specialised services to respond to their health challenges, so that their chances for optimum health are maximised. The child or young personâ&#x20AC;&#x2122;s physical, developmental and psycho-social and mental health needs are to be identified in a preliminary health check. This will provide advice on the specialist services required and the timing of a comprehensive health and developmental assessment. Children and young people are to have their own written health record which moves with them if they change placements. Health record Relevant health information that is in a consolidated form that documents the child or young personâ&#x20AC;&#x2122;s state of health and the identified needs.

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Preliminary health check A preliminary health check aims to establish the on-going relationship between the child, carer and the primary health care provider. The primary health care provider should provide screening and preliminary assessment of the child or young person across physical health, developmental and psycho-social and mental health domains. Importantly, this relationship will establish continuity of care and enable support of both the child and the carer over time. The preliminary health check should provide guidance on the clinical specialties required and timing of the Comprehensive Health and Developmental Assessment. Source: Department of Families, Housing, Community Services, and Indigenous Affairs together with the National Framework Implementation Working Group (2010), An Outline of National Standards for Out-of Home Care: A Priority Project under the National Framework for Protecting Australia’s Children 2009 – 2020.

The standards in United Kingdom specify that to be successful in improving health outcomes for this vulnerable population any guidance, structures or plans must have as its central focus a partnership process which builds on the views and priorities of the children and young people themselves. The individual child or young person should be at the centre of the process of health assessment, planning, intervention and review. Box 3: Messages from Looked-After Children in the UK Messages from Children and Young People

• Young people value the idea of seeing and keeping their own health records. • Young people’s experience of medical examinations is negative - the event is often impersonal, lacking in explanations and without recognisable outcomes for them.

• Policies and procedures should be established to ensure that the needs of the system do not intrude on a child’s appropriate need for personal privacy.

• Young people feel angry at the failure of professionals to respect the confidentiality of their health information.

• Information and advice should cover: sexual health, fitness, stress, depression, contraception, drugs, skin and hair care and how to use a GP practice.

• Better information, advice and support should be available for mental health services. Source: Department of Health (2002), Promoting the Health of Looked After Children, London: Department of Health Publications

The regulatory framework under this Act provides for an annual health assessment of each child over five or young person who is looked after, supported by statutory reviews of their care for which social services are responsible. The objectives are to ensure that health needs are properly assessed and appropriate health care interventions are provided. It recognises 12


that attention needs to be given not only to physical examination but to personal history, birth and family histories, growth and development, emotional, dental and oral health. The Children Act of 1989 in the UK provides a clear framework of making arrangements for the placement of the child. Roles and responsibilities of all members in this process are outlined and the health management system is integral to this. In the UK, these functions are directly linked to their public health system i.e. the National Health Service (NHS). Box 4: Standards for Looked-After Children in the UK Some standards listed for looked-after children in the UK:

• Each child or young person should have a holistic health assessment on entering care; • This assessment should be undertaken by a suitably qualified medical practitioner, but review assessments may be carried out by an appropriately qualified registered nurse/ midwife;

• The first health assessment should result in a health plan by the time of the first review, four weeks after becoming looked after;

• Where children have already been assessed under the Assessment Framework, this assessment should be updated in the light of the child’s changed circumstances;

• Attention should be given to the continuity of previous plans and interventions where appropriate;

• All health staff with information about the child’s health should ensure that this is made available to the person undertaking the assessment as soon as possible;

• Local areas may find it helpful to have a system of identifying one health professional to undertake the co-ordinating role for an individual child’s health;

• Health assessment is not an isolated event, but part of a continuous process; • Successful health assessments will require a flexible approach, appropriate to the child or young person’s age and stage of development;

• The health plan should clearly set out the objectives, actions, time-scales and responsibilities, arising from the health assessment;

• The health plan will be reviewed in line with the statutory review time-scales. Health assessments must be undertaken twice a year for children under 5 years, and annually for children and young people 5 years and over;

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• The local arrangements for reviewing the health plan, will balance the sensitive and confidential nature of the child and young person’s health information whilst ensuring it is appropriately integrated into the overall care plan;

• The lead health record for the looked-after child or young person should be the GP-held record. A copy of the health assessment and plan should be part of this;

• The health plan should be continued as appropriate when the child returns home. Source: Department of Health (2002), Promoting the Health of Looked After Children, London: Department of Health Publications

In other countries, these standards support the development of an effective health system that is integral to any institution/care giver that provides care for children. However, we will have to build-in standards with the specific understanding of children who are homeless when developing health protocols for them. The response to their health needs has to be seen as part of a continuum so as to ensure continuity from the context they come from, their lives at the home and their lives after they leave the home. The standards and protocols, therefore, should provide a set of underpinning principles on which services should be based as well as outline some key standards that need to be implemented. Some of the standards developed by the above-mentioned countries have been adapted into our general principles. The next section spells out the approach we have taken towards building a health programme for children in residential care and then moves on to specific sub-sections on the components of the health programme. This handbook is a shift from a medical approach towards a more holistic assessment of health needs of children between the age group of 4-19 years. However, it focuses primarily on general physical health care since it is part of a body of work in which programmes for mental health are being dealt with in greater detail in another module.

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Chapter

3

Approaches in Long term Residential Care

This section looks at the approaches that one may take in developing a health intervention programme for street children in residential care. The special health characteristics and needs of street children have been highlighted before and we have seen that the existing approaches to addressing health needs of children in India are varied. It is extremely important to recognise that street children have all the needs and rights that other children have as well as special additional needs. Thus, a comprehensive programme for their health care in the setting of residential care needs to take into account all the requirements of a good residential school health programme as well as make additional arrangements for special needs. Traditionally there are two broad approaches to addressing health needs of children in homes: ••

••

One approach is a medical approach where the focus is on curative services and heavily dependent on qualified medical practitioners that include physicians and specialists. Services are then provided on a case-by-case basis. Another is a health worker approach that would rely primarily on the health worker at the home who has training and skills to address the health needs of the children. The health worker takes a comprehensive view of health and focuses more on preventive and promotive aspects of health. Children’s medical needs are primarily addressed at the primary level i.e. at the level of the health worker. In cases where there is need for secondary or tertiary level services, the health worker then approaches hospitals or doctors who are empanelled with the home.

Between the two traditional approaches, the health worker approach is feasible provided there is a good rapport with government hospitals and doctors. This is specially recommended if an organisational relationship can be established between a government health care institution, such as a medical college hospital, and the home. The medical approach is not recommended since it is wasteful and also over medicalises many health issues that can be dealt with better through prevention, promotion and primary level care. Keeping this comprehensive view in mind, a balance between the two approaches is seen as the way forward. This approach also recognises that all the staff members in any children’s institution, irrespective of their roles and responsibilities, are fundamentally health workers and thus need training in developing an overall perspective. Further, a public health imagination and sensitivity to the health of children is important.

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It is well known that trained health workers can play a key role in access to health care, as amply demonstrated by the national ASHA programme and many successful NGO led programmes such as Jan Swasthya Sahyog (Bilaspur), Mobile Crèches (New Delhi) and SEARCH (Gadchiroli). It has also been rather difficult to induct clinical practitioners into public health practice, and it is very expensive to run a doctor-led programme. However, it may be best to have a combination of both in the specific context of street children in homes. Thus, the programme should work through a team of thoroughly trained, well-supervised and supported health workers along with a panel of doctors who visit periodically for well-defined services. These should be further supported and advised by a Health Management Advisory Committee that includes a doctor from the panel that service the homes, a public health specialist and some other specialists (mental health and gynaecology in particular) on a voluntary basis. Another key resource that can be added to the health team is an AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) specialist who can provide valuable training to the health worker team on the use of simple home remedies and an AYUSH formulary for health workers to use themselves, as well as provide on-site AYUSH services. One of the preliminary tasks while setting up a health programme is to map existing resources in the area that may comprise of friendly doctors who are willing to help, government dispensaries, health centres, hospitals, social organisations and others. It will be important to gather information on existing health schemes by the government. These would vary from state to state. It is also important to have information on the existence of government supported â&#x20AC;&#x2DC;free bedsâ&#x20AC;&#x2122; in large corporate hospitals and be aware of the procedures required to utilise these. Some children with severe disorders may require intense financial investments, such as for chemotherapy or transplant. Maintaining a supportive network for referrals, financial aid and volunteer action has been an important strategy in the experience of those who have been running such health programmes. The working of all sub-systems that contribute to the overall health of children is a challenging task. Health management systems and monitoring mechanisms need to be in place to ensure the smooth functioning of all systems. While all homes will be functioning specific to the contexts in which they have been established, it is important that there be a minimum common approach and framework when addressing health needs. Existing Models for Residential care This section discusses the existing models that address the health needs of street children. There are no documented health protocols for street children living in homes, available in the Indian context. The existing models have adapted health interventions to their contexts. There is no standard model that could be replicated but there are approaches and 16


frameworks that could be adapted. The two models of health systems for children in homes documented here are both successful yet have somewhat different approaches. Health Models in Sneh Ghars, Delhi The first model that we discuss is that of Sneh Ghars, co-ordinated by the Centre for Equity Studies (CES) in Delhi that runs homes for children in Delhi, Hyderabad and Bangaluru. The homes in Delhi are in partnership with the Delhi government, where the government provides the infrastructure and space while the NGO manages and funds the programme for the children. Field workers of the organisation bring in the children from the streets to the homes. The Child Welfare Committee (CWC) also sends some children. In the homes, the systems that are essential to run a health programme in any institutional set up are in place. The approach is holistic and there is a balance maintained between the preventive, promotive and curative services. The main objectives of the health programme of the campaign are: „„ To ensure the preventive, promotional and curative physical and mental health care

of all children in residential care, including immunisation, hygiene, health education, de-addiction, nutrition tracking, individual and group counselling. establish linkages with public and private health care institutions and functionaries „„To at the primary, secondary and tertiary levels for the care of the children. provide emergency curative health care support (including for serious ailments) „„To even to those children who are on the streets and in contact with the home, but not actually living in the homes. There is an attempt in these homes to have all systems in place that include the wider determinants of health – food and its quality and quantity, adequate water supply and regular checks and treatment of water, sanitation facilities, hygiene of the home and its maintenance, check-ups of new entrants and regular check-ups of resident children by a visiting doctor, immunisation, de-worming at intervals, linkages with specialists and public hospitals in the vicinity for referrals and emergency services and eye and dental camps at regular intervals. The homes also meticulously document and maintain records for each child. But the challenges are plenty. Homes given by the Delhi government are in a dilapidated condition and a lot of work is required to put the entire infrastructure in place. In one of the homes there is a severe constraint of space as against the number of children who live there. This leads to further health problems from overcrowding such as skin diseases. The campaign does not refuse any child who seeks entry into the home. Thus the living conditions often create recurrent hygiene related issues and increased prevalence of morbidities. Therefore the real test lies in making the health system functional given these challenges. 17


Health Models in Rainbow Homes for street children, Kolkata The other important model is that of Rainbow Homes run by the Loreto Convent in Kolkata. There are six schools that house Rainbow Homes on their top most floors, which have been well covered. It is a unique model of integrated education where the Rainbow children are integrated into a mainstream school and the Loreto Convent school children participate in the Rainbow Home programmes. The Homes are very well kept in terms of hygiene and the quality of food is good. Preventive aspects are the primary focus though there is a nurse at the Home at all times. This Home deals with illness on a case-by-case basis. Each of the Homes is near a public hospital with which they have a good rapport. There are no routine check-ups by doctors. However, the children participate in all the health camps of Loreto School for their check-ups such as dental checks and eye checks. There is not much routine documentation either. Every child has their case history recorded on entering the Home and any medical services availed thereafter are filed in terms of referral slips, doctor’s slips and prescriptions. The focus is mostly on a good environment, lot of space and plenty of good food for the children. Contact is maintained with the family and once a month there is a meeting organised between the children and parents, which is compulsory for parents to attend. Children are allowed to visit their families during festivities and vacations. One advantage of this model is that these Homes are housed in the schools. This provides them with well-functioning systems and a developed infrastructure from the very beginning. This particular model works on the principle that the home is like a family environment, and just as we do not organise health services specifically for children in families we do not need to ‘target’ street children. Just as a care giver in the family would immediately identify a health need and take action, so does the care giver in the residential home. However, it is crucial to note that they do participate in the school health programme just as any child living at home would. In the first case study, the ‘home’ is organising systematic services because it is working both as the ‘school’ as well as the ‘family’. In the second case, the children are availing of the services of the school and the ‘home’ is performing the function of the family. Thus the choice of model depends on the circumstances of the home.

18


Chapter

4

Ethical issues of Health in Long term Residential Care

To address the challenge of reaching out to children on the streets comprehensive long-term residential care can be used for the entire duration of childhood and youth, but in ways that are voluntary and non-custodial. Here the residential institution is being called a ‘home’. The security of a non-custodial home from where they can move in and out gives them a sense of independence. This institution called ‘home’ provides them everything that any other ordinary home would provide – shelter, food, education, health services and physical and emotional security. This home takes care of their overall well-being even though the children may still continue to be in touch with their families or may or may not want to visit them. It also prepares them for life beyond this shelter i.e. once they are out of here and on their own. Some ethical considerations in providing care There have been many debates on the ethical issues of health programming for children. We present some of these which may act as guides for any health programme. These ethical guidelines need to be stated for all health professionals/staff providing care. ••

••

The balance between autonomy and paternalism - Health programmes can generally be paternalistic and one-sided but they are better if based on respect for every individual who is part of the programme. In this case children should be able to participate in their own health issues, take part in decision-making and should be informed of the interventions that are in place – interventions at the individual as well as at the level of the home. In cases of HIV/AIDS screening informed consent should be taken from the children and their parents. Adolescents may be mature enough to take decisions about their health but in case of young children, efforts need to be taken to contact parents and seek consent unless the situation warrants immediate action. Confidentiality – Health workers deal with children through daily routine work. They often have access to private information of individuals and communities. Children also provide the health worker with private information in confidence, and it is their right to have such information about them kept confidential. Failure to keep private information secure and disclosing this information to other people, deliberately or accidentally, is an infringement of confidentiality which may harm the child. For example, information on HIV/AIDS or genetically inherited conditions may bring social stigma and ostracism.

19


Non-maleficence i.e. doing no harm and injustice - The principle of non-maleficence requires health professionals to not intentionally create a needless harm or injury to the child, either through acts of commission or omission. In common language, it is considered to be ‘negligence’ if one imposes a careless or unreasonable risk of harm upon another. Any health worker therefore should provide a proper standard of care that avoids or minimises the risk of harm. This is supported by commonly held moral convictions and by the laws of society as well. In a professional model of care one may be morally and legally blameworthy if one fails to meet the standards of due care. It is clear that mistakes occur; however, this principle articulates a fundamental commitment on the part of the health worker to protect the children from harm. •• Beneficence - The ordinary meaning of this principle is the duty of the health worker to be of benefit to the child, as well as to take positive steps to prevent and to remove harm from the child. These duties are viewed as self-evident and are widely accepted as the proper goals of any health work. On the basis of the discussion above, it is important to state the general ‘culture’ and vision of the programme as one that puts the child first and is respectful, caring, sensitive and responsive. In a context in which health management is often a top-down and paternalistic process especially where children are concerned, a genuine respect for the privacy of the child should be the foundation for any health programme. ••

20


Chapter

5

Principle Processes of Health care

There are certain principles that need to be followed when a child enters a home. These basic principles involve individual assessment, planning for the child and implementing and reviewing the child’s health at intervals. There should be engagement with the health needs of every child. While some interventions would be generic and all encompassing, there needs to be an individual focus on the health needs of every child in the home. Assess, Plan, Implement and Review Health of a Child Every child on entering the home needs to go through a health assessment which includes a psycho-social assessment as well. Health Assessment of the Child Assessments should be conducted within a standardised and systematic framework that includes a well-taken history of the child – socio-economic context, history of abuse of any kind and experiences of living in the streets. This is to be done by the health worker. The health worker must also do a growth assessment. Following this, a detailed physical health assessment must be done by a medical doctor/physician. The health assessment needs to be respectful, sensitive and age appropriate. Sensitive issues of gender, class, marginalisation and power need to be kept in mind while conducting the assessment, especially since this is the first detailed interaction with the child and involves many personal issues that may be painful. Care must be taken to not at any time push the child beyond his/her comfort levels or traumatise him/her in any way. Thus, conducting the health assessment is a highly skilled task that requires special training, even of the doctors. The health assessment must reflect the general culture of the home and the programme, which puts the child’s well-being first and foremost. It should not be an impersonal and mechanical process (see Box 5). At this point, the child should be allowed and encouraged to make a self-assessment and express it in his/her own way – through drawings or the written word – about what s/he feels about his/her own health. Like the health assessment by others, this can be an on-going process, and should be filed alongside the other assessment formats (see Box 6).

21


Box 5: The Content of Health Assessment For Under 5 For under-fives, the focus will be on:

• • • • • • •

Physical health Growth Diet Immunisations Teeth Experience of caring relationships and emotional well-being Monitoring developmental milestones, in particular the development of - speech and language, gross and fine motor function, vision and hearing, play and pre-literacy skills, social and self-help skills.

The Middle Years - 5-10 years For primary age children the focus will be on:

• • • • • • • • • • • • • • •

Physical health and management of specific health conditions e.g. asthma Growth monitoring Communication skills Self-care Ability to make relationships and to relate to peers Mental and emotional health including depression and conduct disorders Exercise and understanding the need of a healthy lifestyle Provision of a healthy balanced diet Progress at school Awareness of basic safety issues including road safety To recognise and cope with the physical and emotional changes associated with puberty Access to accurate and simple information about sexual activity Immunisation Dental health Experience of caring relationships

Adolescence and Leaving Care – 11-18 years For secondary school age children and young people the focus will be on:

• Ability to take appropriate responsibility for own health, including management of specific health conditions e.g. asthma, diabetes

22


• • • • • •

Communication and interpersonal skills Educational and social progress Lifestyle including diet and physical activity Ensuring that immunisations are up to date Mental and emotional health including depression and conduct disorders Understanding of issues relating to sexuality and sexual activity including its role in relationships; contraception; sexually transmitted infection and the particular risks of early sexual activity.

• Access to sources of information and advice about a range of health issues including the risks of alcohol, tobacco and other substance use and access to sources of advice on modifying health risk behaviours.

• For care leavers to have a full copy of the social care health records (including genetic background and details of illness and treatments) and be equipped to manage their own health needs. Source: Adapted from Department of Health (2002), Promoting the Health of Looked After Children, London: Department of Health Publications

Planning A detailed report should be brought out for every child after the assessment in order to draw out a health plan. If there is a history of abuse or if the child is malnourished and there is concern related to growth of the child, then it calls for immediate planned interventions and action. This too needs to be done by the team with the health worker at the centre. Implementing The health worker should be aware of the health plan drawn out for every child and must have a checklist of interventions and actions that need to be taken. The interventions need to be prioritised and ensured that they happen on time. While each child will have a health plan specific to his/her health needs some protocols would be mandatory for every child who enters the home. Here, de-worming medicine, immunisation (tetanus, MMR, typhoid) needs to be administered. It should be noted that children on the streets often group-up and offer support to each other in many ways. Thus, programmes dealing with street children have effectively used child-to-child and peer support strategies to achieve impact on health issues. Review A review of the child (including self-review) should be mandatory every 6 months. This helps in following up whether action has been taken according to the health plan and a reassessment of the health status of the child can then be done. 23


Follow-up of children who leave the home (to be with their families or to be on their own): In a non-custodial approach where a child may leave the home in between, attempts should be made by the staff at the home to get in touch with the child or the family and ensure actions are taken according to the plan. In case the child returns to the home after a period of time a new health assessment should again be conducted. Box 6: Contents of an Individual Health File The Individual Health File should contain:

• General Assessment – The Child’s Detailed History • Physical Health Assessment and Medical records • Psycho-social Assessment • Child’s Own Assessment • Growth Chart • Health Plans and Reviews

Summary The general principles of health care are: •• •• ••

•• •• •• ••

•• ••

24

An attitude of respect, care and sensitivity, consistent with the culture of the programme should be encouraged. Each child or young person should have a holistic health assessment on entering care. suitably qualified medical practitioner, counsellor as well as the health worker A should undertake this assessment. Any appropriately qualified and trained health worker may carry out review assessments. The child must also have an opportunity for self-assessment. first health assessment should result in a health plan by the time of the first review, The four weeks after coming in to the home. Attention should be given to the continuity of previous plans (if any) and interventions where appropriate. health staff/field workers with information about the child’s health should ensure All that this is made available to the person undertaking the assessment as soon as possible. Health assessment is not an isolated event, but part of a continuous process. Successful health assessments will require a flexible approach, appropriate to the child or young person’s age and stage of development.


•• •• ••

••

The health plan should clearly set out the objectives, actions, time-scales and responsibilities, arising from the health assessment. The health team headed by the health worker should ensure that the health plan is implemented through the systems that are in place. health plan will be reviewed in line with the statutory review time-scales. Health The assessments must be undertaken twice a year for children under 5 years, and annually for children and young people 5 years and above. There will be appropriate measures taken towards thorough preventive and promotive health and will encompass every child and adolescent in the home.

25


Section

II

Health Systems at the Home

Health is a multi-dimensional concept. Therefore, several systems have to be at work simultaneously. Access to basic needs like food, safe water supply and sanitation, other infrastructural issues, and adequate health services all add up to the health status of the children and get reflected in their illnesses. However, the issues related to the social determinants of health have been tackled in detail in the module on housekeeping. This module should also be seen in continuation to the one dealing with mental health as the physical and emotional health needs of children are interdependent. The systems that need to be in place are depicted in Fig. 1.

Fig.1 â&#x20AC;&#x201C; Health Systems at a Home for Children

26


Chapter

6

Preventive and Promotive Health Programmes

Improved health outcomes for children in homes require the focus to be on health promotion that goes beyond meeting the health care needs of the individual child. This section looks at the environment of the home, the infrastructure of the home, space availability per number of children staying, availability of food which is healthy and nutritive in order to guarantee a healthy lifestyle. The Preventive and Promotive Health Programme This includes the following: •• •• •• ••

Food and Nutrition Infrastructure and Hygiene in the homes Growth Monitoring Health Education and Health Camps

Food and Nutrition Good quality food is essential for the well-being of children and adolescents as these are periods of continuous growth and development. Studies show that most street children do not consume adequate food5, and that the quality of the food they eat is very poor. Thus, the food provided has to cover existing deficiencies and maintain the usual requirements of growth. (a) Meal planning ‰‰ A

good menu helps to provide adequate nutritional requirements of calories, fat, proteins, minerals and vitamins. The diet should contain the five basic food groups: cereals, pulses, fruits and vegetables, milk products, fats and oils (see Fig. 2). Children’s diet should have high protein content. Fish, egg and lean meat are rich in protein. ‰‰ Meal planning should be such that the menu is simple and nutritious. Seasonal and locally available vegetables and fruits should be used to have cost effective diets.

http://www.shelterdonbosco.org/street.htm

5

27


‰‰ There

should be sufficient iron rich food in the diet like meats, green leafy vegetables and eggs. Foods that help in the absorption of iron include meats, fruits and vegetables rich in Vitamin C. Spinach, tea and coffee inhibit iron absorption. Therefore there needs to be a proper balance of nutrients in the meals.

‰‰ There are methods to minimise the loss of

nutrients by using sprouted grams, malted cereals and fermented foods that enhance nutritive value. Using a pressure cooker helps conserve the nutrients. Vegetables like potatoes should be boiled with their skin to prevent nutrient loss. Iron utensils could be used to cook food.

‰‰ Washing

vegetables before cutting is better than doing so after cutting them in order to retain water-soluble vitamins.

‰‰ Cooking

should be done using a variety of processes like boiling, steaming, frying and baking.

‰‰ Meals

should be able to provide variety in terms of colour, texture and

taste. ‰‰ Artificially

flavoured items and foods with too many preservatives need to be avoided.

‰‰ There should be at least four meals during the day (a substantial breakfast,

lunch, an evening snack and dinner) along with milk twice a day. ‰‰ Children

should be encouraged to drink lots of water in a day.

‰‰ Special

diet should be given to children who are severely, moderately or mildly malnourished.

‰‰ Children

who are out for most part of the day must be given lunch boxes.

‰‰ A

meal chart giving a detailed schedule and menu for all meals for all seven days must be available to all (see Table 1).

‰‰ Portions

will vary according to age and the food distributor should be made aware of this.

‰‰ Quality

of food needs to be monitored on a regular basis. Children should be allowed to give feedback on the type of food, its quality and quantity. They should take part in deciding the menu.

28


Fig. 2: A food pyramid showing the composition of a balanced and healthy diet Source: Compiled from various sources: http://www.elderlynursing.com/foodpyramid.htm; http://www.hsph. harvard.edu/nutritionsource/what-should-you-eat/pyramid/ (accessed 5th May 2011)

Table 1: Sample Menu7 Meal

Time

Sample Menu (will vary according to region and season)

Breakfast (should be substantial)

7:30 am -8:30am

Milk or porridge (everyday) + an egg (at least thrice a week in the form of omelette, bhujiya or boiled egg) + Bread

Fruits (banana) / any seasonal fruit (everyday) The egg and bread could be alternated with: Roti with a vegetable bhujia Idli with Sambar A food pyramid arranges the food starting from the high calorie food at the top to the low calorie food at the base.

6

Reference for recipes and further suggestions on menus is given in Annexure 3. These modules should be made available at homes.

7

29


Light meals 11:00 am (mid-day and in 11:30 am evenings)

Fruit chaat + wheat ladoo + buttermilk Besan chila + curd/buttermilk Wheat pulse ladoo + buttermilk

4:30 pm -5:30 pm

Alu chhole + bread Seasonal fruits

Principal Meals: Same cereal should not be used in both meals Lunch / Dinner (lunch boxes should be provided to children who are not at home during lunch hours)

Lunch: 1:30 pm Depending on the region: - 2:30 pm Roti + Dal + subzi + dahi Dinner: 8:30 pm - 9:00 pm

Khichdi + Curd + subzi Rice + sabud urad + subzi Missi roti + curd + subzi Rice + Arhad daal + subzi + Papad Roti + Alu chhole + curd Bajra cooked + curry + fruits Roti + palak + chana daal Cooked Tapioca + fish curry Rice + fish curry + kheer

Pongal + vegetable curry + buttermilk Rice + Sambar with vegetables +buttermilk Vegetable pulao (with three different vegetables) + Raita

One non-vegetarian item should be preferably given twice a week (chicken / mutton / fish/ egg curry). Similarly desserts should be offered preferably three times a week.

30


(b) Food handlers ‰‰ Food

handlers in the kitchen (cooks and servers) should wear caps. ‰‰ They should be vaccinated against Typhoid and Hepatitis A. ‰‰ There should be hand-washing facilities available for them and their nails should be trimmed. ‰‰ Use of long handled ladles for food and water should be encouraged. ‰‰ Use of tongs for serving food must be ensured. Infrastructure and Hygiene of the Home The physical space that a child spends most of his/her time in must be healthy and safe. Therefore, the ‘health’ of the home here is very important. The following points highlight the areas that will ensure the vitality of a home: „„ Homes

need proper ventilation and lighting. „„Clean water supply from the government water board – Tanks that store water should be cleaned once a month. Water should be tested every month and treated. In case of a diarrhoea epidemic, the water should be immediately sent for testing and proper measures to ensure clean drinking water should be adhered to. „„Bathroom/Toilets – Regular cleaning by all staff and residents in rotation is a must. Taps and flush systems need to be monitored to check that they are working properly and there is adequate stored water. should be proper mechanisms in place for waste disposal as well as medical „„There waste (used syringes/medicines that have crossed expiry date). „„Fumigation of the home – The home should be kept free of pests and fumigation at regular intervals should be carried out. „„Space to play – If there is some open space around the home, a green area could be developed that has plants that children may take an interest in and there should be enough space to play. allow responsible attachment and sharing of affection and should be „„Pets encouraged. However, the pets need to be inoculated as appropriate and kept clean, healthy and well-fed themselves. Children can be given responsibilities in turn to look after the well-being of pets. Caution should be exerted as some children may have an allergic reaction to pets. Growth Monitoring As discussed before most children suffer from hunger and malnutrition. Food that is available to them is also usually of the wrong kind. Their everyday diet does not contain much nutritive value. Therefore, growth monitoring is an important component of health assessment. The purpose is to determine whether a child is growing ‘normally’ or has a growth problem or a tendency towards a growth problem that needs to be addressed. On entering a home 31


a child’s height and weight need to be measured and these indicators must be interpreted so that interventions can be made. Growth assessment is aimed at identifying children who need urgent intervention, such as therapeutic or supplementary feeding. Growth must be subsequently monitored at regular intervals. This includes: „„ Measurement

of Weight and Height „„Calculation of Body Mass Index (BMI) „„Plotting these measurements on growth charts „„Interpreting growth indicators (a) Measuring a Child’s Growth To take measurements the health worker must record the weight of the child and height of the child. Weighing the child: Type of scale: The scale used to weigh children must be solid and durable and should be able to measure up to precision. How to weigh: Before weighing a child, the child must take off any heavy outer clothing and footwear and then stand on the scales. Ask the child to stand in the middle of the scale, feet slightly apart (on the footprints, if marked), and to remain still. The health worker should then note the reading. Check the accuracy of the scale: One should weigh known weights of 3, 5, 10, and 20 kg. If the weights are not accurate, calibrate the scale if possible. Otherwise, if the error is consistent (e.g. off by +0.2 kg constantly), adjust measurements accordingly (e.g. by subtracting 0.2 kg). If measurements are off by variable amounts, the scales may need to be replaced. Measuring height: Type of board: To measure height, use a height board mounted at a right angle between a level floor and against a straight, vertical surface such as a wall or pillar. How to measure: The child must take off any footwear and should be helped to stand on the baseboard with feet slightly apart. The back of the head, shoulder blades, buttocks, calves, and heels should all touch the vertical board. The health worker must help the child to stand straight with the head in position. The health worker will use one hand to hold the head in position and gently bring down the headboard to rest firmly on the top of the head of the child and compress the hair.

32


To get accurate measurements: Check that the joints are tight and straight. If not, tighten or straighten them. Check that the measuring tape can be read. If it is too worn out to be read, it should be replaced. (b) Calculating BMI and Plotting the Measurements The health worker has to note down the age of the child (for example – 6 yrs and 2 months), the weight of the child in kilogramme and the height of the child in centimetres (convert to metres). Growth indicators that the health worker will need to calculate: ‰‰ BMI

(Body Mass Index) for age - BMI is a number that indicates a person’s weight in proportion to height, calculated as kg/m2 . BMI for age is a growth indicator that relates BMI to age. This is useful to know thinness or fatness of an individual. ‰‰ Height for age – A growth indicator that relates height to a child’s age. This is useful for tallness. ‰‰ Weight for age – A growth indicator that relates weight to a child’s age. Charts that show standard patterns of the expected growth rate over time enable health care providers to identify children at risk of becoming undernourished or overweight early, rather than waiting until a problem level is reached. WHO recommended growth charts (Annexure 3) should be made available to all the homes. The following charts are available: BMI for age (5-19 years) for boys and girls; Height for age (5-19 years) for boys and girls and Weight for age (5-10 years) for boys and girls. For those children who are in the age group of 5-10 years, all three charts must be plotted. For those in the age group of over 10-19 years, only BMI for age and height for age charts need to be plotted. To plot the point on the graph the health worker must understand what is represented on the x-axis and y-axis. X-axis represents age while y depicts weight, height or BMI. The plotted point on a graph will be a line extended from a measurement on the x-axis (e.g. age) that intersects with a line extended from a measurement on the y-axis (e.g. weight). (c) Interpreting the Measurements Once the point has been plotted on the growth chart, the health worker needs to know how to interpret it. The line labelled 0 on each chart represents the median, which is, generally speaking, the average. The other curved lines are z scores8 that indicate distance from the average.

Z scores are standard deviation scores

8

33


The points plotted need to be read from Table 2 below and their interpretations are written in the box. Table 2: Interpreting Scores Z Scores

Height for age (5-19 years)

Weight for age (5-10 years)

Above 3

Tallness is rarely a problem, unless it is so excessive that it may indicate an endocrine disorder such as a growth-hormone-producing tumour

A child whose weight-for- Obese age falls in this range may have a growth problem, but this is better assessed from BMI-for-age Overweight

Above 2 (between z score lines 2 and 3) Above 1

BMI for age (5-19 years)

Possible risk of overweight

0 (median) Below -1 Below - 2 (between z score lines -2 and -3)

Stunted (note 1)

Underweight

Wasted

Below -3

Severely stunted (note 1)

Severely underweight

Severely wasted

Source: WHO (2007), Growth standards for children Measurements in shaded box are in normal range Note 1 - It is possible for a stunted or severely stunted child to become overweight.

Correct measurement, plotting and interpretation are essential for identifying growth problems. It is then critically important to take action to address the causes of poor growth. Growth assessments that are not supported by appropriate response programmes are not effective in improving child health. (d) Actions to be Taken In any situation of growth faltering, the associated doctor should be alerted and a health check up done to rule out any underlying disease like TB that needs specific treatment. In general, all children with growth faltering need extra calories and proteins in the form of more frequent and richer meals along with vitamin and iron supplements. Antibiotics may be required as prescribed by the doctor and de-worming must be ensured.

34


In the age group being considered, if the child does not have a specific underlying illness and has come into the home with mild or moderate malnutrition/stunting, we should be able to see a slow improvement in weight and height just with the care of the home within three to four months. If there is a more severe malnutrition the children may need special foods for a few months (like an extra egg or glass of milk a day). Any child who starts to become malnourished while in the care of the home must be urgently referred and investigated for an underlying disease that may be hidden, including TB, malignancies, HIV/AIDS, mental ill-health and hormonal disturbances. Health Education and Health Camps (a) Health education (on substance abuse /drug misuse and addiction, sex education, personal care and life skills) Feedback from children and adolescents indicate that they want honest and credible information on drugs, alcohol, tobacco and other volatile substances. It becomes even more important for them to be aware of the choices they need to make once they leave the home. The objectives of health education can then be listed as:9 ‰‰ To

help children to become aware of health – the different ways in which it is defined, to develop a positive attitude towards health as individuals and be collectively responsible to achieve it. ‰‰ To help children become aware of appropriate health needs at a particular age(s) through information and communication. To encourage them to learn desired skills and form desired habits about food, exercise, sleep, rest and relaxation in their everyday life. ‰‰ To help children know and accept individual and collective responsibility for healthy living at the home and school. ‰‰ To help children instil life skills such as self-esteem, decision-making, goalsetting, effective communication, stress management, character building, and sensory motor skills; ensuring that they become an integral part of each child's life and personality. ‰‰ To help children to be acquainted with nutritional requirements, personal care, environmental hygiene, sanitation, pollution and common diseases as well as measures for their prevention and control. ‰‰ To help children know their status of health, identify health problems and be informed for taking appropriate remedial measures.

These objectives of health education are those defined for NCERT school health education

9

35


‰‰ To

create awareness among children about rules of safety in hazardous situations to avoid accidents and injuries. To acquaint them with first-aid measures about common sickness and injuries. ‰‰ To help children learn correct postural habits in standing, walking, running, sitting and other basic movements so as to avoid postural defects and physical deformities. ‰‰ To help children understand the process of growing up during adolescence, as well as about HIV/AIDS, drug abuse and issues surrounding sexuality. ‰‰ To address the physical, psycho-social needs of differently-abled children. To meet the above objectives the following points need to be kept in mind: (i)

The health worker should be trained to handle the sessions (sessions considered important for health education have also been listed in the section on training).

(ii) Issues relating to sexual health (understanding their bodies, reproductive health and information on contraceptive methods, STIs/RTIs, and substance abuse) are highly sensitive and if the health worker is handling the sessions s/he should have received appropriate training on the same. (iii) Local NGOs specialising on these issues could be invited and a list of resource persons should be maintained to take sessions along with the health worker. (iv) There should be maximum involvement of children and sessions must be interactive with lots of activities and role plays. (v) There could be health education sessions for parents too who visit their children at home. One day in a month should be kept for parents to visit the home and attend the health education sessions on any of the above-mentioned topics. (b) Health camps (Eye, Dental, Immunisation) ‰‰ Eye

and dental check-ups could be organised at regular intervals (once in six months) and important immunisations can be covered through health camps. ‰‰ The Government PSM department, some local NGOs, or the panel of institutions and doctors listed by the home could be involved in delivering these services. The health worker and home manager should have set the dates for the camps well in advance. ‰‰ Appropriate physical arrangements should be made to have a successful camp such as space with enough privacy for proper examination, sufficient wo/ manpower to assist the attending doctors, provision of water and toilets, etc. ‰‰ There should be a proper follow up of those children who have been referred for further eye or dental treatment. 36


Chapter

7

Curative Health Programme

The Curative Health Programme This section deals with the curative aspects of the health programme of a home. Even though the main thrust of the programme is on preventive and promotive measures, it is essential that the health care workers be well trained to deal with some basic problems. This programme is divided into two aspects: •• ••

First Aid Programme Common Childhood Illnesses

First-Aid: Dealing with Emergencies10 First-aid is the immediate treatment given to a patient of an accident, sudden illness and other emergencies before regular medical help is provided. Therefore, it provides the initial care for any illness or injury. Any individual can be trained in first-aid and these skills can prove to be life saving. This section discusses some general principles of first-aid. There are three objectives of first-aid: „„To preserve life „„To prevent further injury and deterioration of the condition „„To put the injured child under medical cover at the earliest In the home situation, all staff should have had first-aid education as part of their induction training. The first-aider must have a basic understanding of what the vital body functions are and what the consequence would be if they were damaged or not functioning. There are some basic principles that the first-aider should follow – s/he should be calm, observe the situation and assess it carefully, identify the nature of illness and act quickly. The child should not be left alone nor should there be any crowd around him/her. The first-aider should instruct someone responsible to call for medical help and immediately provide firstaid. First-aid kits should be adequately stocked at all times and should be accessible to all staff and anyone else who has received first-aid training (see Box 7).

This module touches upon some emergencies that need immediate first-aid but every home should have first-aid modules available with them and all staff must be adequately trained. There should preferably be training on Primary Trauma Care (PTC) for first responders. Training courses are available on PTC, for example at http:// www.ptcdelhi.com/ and for detailed knowledge on first-aid, St. John’s ambulance first-aid modules are the most comprehensive.

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Box 7: Contents of the First-Aid Box First-Aid Box should contain: • Savlon Bottles (antiseptic for cleaning cuts and wounds) • Povidone - Iodine Ointment (for dressing cuts and wounds) • Diclofenac gel (for local application over a painful joint/area) • Adhesive Bandage • Gauze Bandages • Elastic Bandage • Cotton Wool • Disposable Surgical Gloves • Scissors • Tweezers • Soap • Safety Pins • Torch

(a) Injuries and Accidents There are certain physical and developmental characteristics that make children more vulnerable to injuries. Their internal organs are not mature and well protected, the neck muscles and spine that protect the body are not strong, they have small fingers that fit into small dangerous spaces, such as electrical outlets, small airways that allow for easy choking, their bones are still growing and can break easily. Apart from these physical characteristics the developmental characteristics include the fact that they are natural explorers and curious about their environment and do not fear dangerous situations. They imitate adult behaviour that may be dangerous. Therefore, safety protocols should be in place in any residential situation and this has been explained in detail in the housekeeping manual. For example, drugs should always be kept in a locked cupboard by the health worker, the roof and terraces must have high enough parapets to prevent falls, no makeshift electrical connections should be in use like the use of naked wires instead of plugs, etc. There are different kinds of injuries – bruises due to a fall or push, deep wounds and excessive bleeding, burns (minor and major), injury to bone (sprain and fractures), injury to the eye, electric shock. Minor cuts and bleeding: Any break in the surface of the skin (wound), will not only allow blood and other fluids to be lost, but also allow germs to enter the body. If the wound is minor, the aim of the first-aider is to prevent infection. Some closed wounds such as bruising could indicate an underlying 38


injury and first-aiders need to be aware of the cause of injury as this may alert them to a more serious condition, such as internal bleeding. Severe wounds may be very daunting to deal with but the aim is to prevent further blood loss and minimise the shock that could result from the bleeding. Since an open wound is at risk of becoming infected, it is important to maintain good hygiene procedures to guard against cross infection between the first-aider and the child. First-aid for minor cuts: In case of minor cuts, scratches and grazes the first-aider should wash his/her hands, clean the cut, if dirty, under running water with savlon or soap and pat dry with a sterile dressing. The cut could be temporarily covered and the surrounding area should be cleaned and dried. The cut should then be covered with sterile dressing or plaster. First-aid for severe bleeding: If there is severe bleeding, direct pressure should be applied for five minutes by the clock to the wound with a clean pad, until sterile dressing is applied. The injured limb should be raised and supported and the child should be made to lie down as s/he may be in shock. Bandage the pad or dressing firmly to control bleeding, but not so tightly that it stops the circulation to the fingers or toes. If blood seeps through the first bandage, cover with a second bandage. If the blood continues to seep through this bandage too, apply pressure again as described above. Nose Bleeding: Bleeding from the nose most commonly occurs when tiny blood vessels inside the nostrils are ruptured. This is due either because of a blow to the nose, or as a result of sneezing, picking or blowing the nose very hard. Nose bleeds may also occur as a result of high blood pressure. Most nose bleeds do not indicate anything serious and resolve on their own. Many children have repeated bouts of nose bleeding without any ill effects. First-aid: The first-aider should advise the child - to sit down; to put the head forwards to allow the blood to drain from the nostrils; to breathe through the mouth (this will also have a calming effect); not to speak, swallow, cough, spit or sniff because this may disturb blood clots that could have formed in the nose; and to pinch the soft part of the nose for 10 minutes in order to exert pressure. If the bleeding has not stopped, the child should be told to reapply the pressure for two more periods of 10 minutes each. Once the bleeding has stopped and with the child still leaning forwards, the area around the nose should be cleaned with lukewarm water. Finally, the child should be advised to rest quietly for a few hours. The child has to be told to avoid exertion and in particular, not to blow the nose, because these actions will disturb any clots. The childâ&#x20AC;&#x2122;s blood pressure should be checked at least once at the first nose bleed to make sure s/he does not suffer from high blood pressure.

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Burns and Scalds: First aid: Any burns - Start cooling the burn immediately under running water for at least 10 minutes Make the child lie down and make him/her as comfortable as possible. Continue to pour cold water profusely over the burn for another ten minutes or until the pain is relieved. The first-aider should wear disposable gloves and try and remove any jewellery, watch or clothing from the affected area - unless it is sticking to the skin. If a large area, for example a whole limb, has suffered from burns it is better that the child be taken to the casualty immediately. All deep burns of any size require urgent hospital treatment. First-aid: Clothing on fire - Stop the child from panicking or running as any movement or breeze will fan the flames. Drop the child to the ground and if possible, wrap the child tightly in a coat, curtain or blanket (not the nylon or cellular type), rug or other heavy-duty fabric. The best fabric is wool. Roll the child along the ground until the flames have been extinguished. The first-aider should not use lotions, ointments, creams and adhesive dressings on burns and should not break blisters. Fractures: Recognition: The first-aider should be able to recognise a fracture by looking for â&#x20AC;&#x201C; swelling, unnatural range of movement, immobility, grating noise or feeling, deformity, loss of strength, twisting, shortening or bending of limb. First-aid: The first-aider should support the injured limb, immobilise the part, provide pain relief and immediately seek medical help. Eye Infection or Splinter in Eye: A speck of dust, a loose eyelash, or some particle can float on the white of the eye. Usually, such objects can easily be rinsed off. However, the first-aider must not touch anything that sticks to the eye, penetrates the eyeball, or rests on the coloured part of the eye (iris and pupil) because this may damage the eye. Instead, make sure the child gets medical attention quickly. Recognition: Blurred vision, pain or discomfort, redness or watering of eyes and eyelids screwed up in spasm. First-aid: The aim of the first-aider should be to â&#x20AC;&#x201C; make the child sit down facing the light; stand behind the child and gently separate the eyelids with a finger and thumb; ensure to examine every part of the eye, and ask the child to look up, down, left and right. If the object in the eye is visible then the first-aider should - wash it out with clean water poured from a glass or a sterile eye-wash bath. To do this incline the childâ&#x20AC;&#x2122;s head towards the injured side and place a towel or pad on the shoulder; pour the water from the bridge of the nose allowing it to run through and flush the eye out. If this is unsuccessful, then lift the 40


object off the white of the eye with a moist swab, the damp corner of a tissue or a clean hanky. If the problem persists, seek medical help. If the object is under the upper eyelid then ask the child to pull the upper lid down over the lower lid as the lower lashes may brush the object clear. The first-aider should not touch anything that is sticking to or embedded in the eyeball or the iris. An eye pad should be placed over the eye and medical help should be sought. (b) Head Injury All head injuries are potentially serious and require proper assessment because they can result in impaired consciousness. Injuries may be associated with damage to the brain tissue or to blood vessels inside the skull, or with a skull fracture. A head injury may produce concussion, which is a brief period of unconsciousness followed by complete recovery. Among the common causes of concussion are traffic incidents, sports injuries and falls. Concussion produces widespread but temporary disturbance of normal brain activity. However, it is not usually associated with any lasting damage to the brain. The child will suffer impaired consciousness, but this will only last for a short time (usually only a few minutes) and is followed by a full recovery. By definition, concussion can only be confidently diagnosed once the child has completely recovered. Some head injuries may produce compression of the brain (cerebral compression), which is life threatening. It is therefore important to be able to recognise possible signs of cerebral compression - in particular, a deteriorating level of response. A head wound should alert the first-aider to the risk of deeper, underlying damage, such as a skull fracture, which may be serious. Bleeding inside the skull may also occur and lead to compression. Clear fluid or watery blood leaking from the ear or nose are signs of serious injury. Any child with an injury to the head should be assumed to have a neck (spinal) injury as well and be treated accordingly. Recognition: The first-aider recognises a concussion when there is a brief period of impaired consciousness. There will also be dizziness or nausea on recovery, loss of memory during the incident and/or a mild and generalised headache. The following are the other danger signs the first-aider should recognise in case of a head injury: Deteriorating level of response and mental state; intense headache; nose bleeds or thin watery discharge from the nose; noisy breathing; slow, yet full and strong pulse; unequal pupil size; weakness and/or paralysis down one side of the body; high temperature; flushed face; drowsiness; noticeable change in personality or behaviour, such as irritability or disorientation. First-aid: Most head injuries should be referred and monitored under the overall care of the doctor and therefore, the first-aider should immediately seek medical help. 41


(c) Choking A foreign object that is stuck at the back of the throat may block the throat or cause muscular spasm. Young children especially are prone to choking. A child may choke on food, or may put small objects into their mouth and cause a blockage of the airway. If the blockage of the airway is mild, the child should be able to clear it; if it is severe they will be unable to speak, cough, or breathe, and will eventually lose consciousness. Recognition: Mild obstruction: Child able to speak, cry, cough or breathe. Recognition: Severe obstruction: Child is unable to speak, cry, cough or breathe; Child will eventually become unconscious if there is no assistance. First-aid: The aim is to remove the obstruction and to arrange urgent removal to hospital if necessary. If the obstruction is mild then encourage them to continue coughing and remove any obvious obstruction from the mouth. If the obstruction is severe then give upto five back blows and check the mouth and remove any obvious obstruction. If the obstruction is still present then give upto five abdominal thrusts (Heimlich manoeuvre11) and check the mouth and remove any obvious obstruction. (d) Heat Exhaustion Heat exhaustion is caused by a loss of salt and water from the body, usually through excessive sweating. Recognition: Headache; dizziness and confusion; loss of appetite; nausea; sweating with pale, clammy skin; cramps in the arms, legs and the abdominal wall; rapid, weakening pulse; rapid, shallow breathing and high fever. First-aid: The aim of the first-aider should be to replace the lost body fluids and salt; to cool the child down, and if necessary to obtain medical help. Help the child to a cool place; get the child to lie down with legs raised; give him/her plenty of water; follow if possible with a weak salt solution - one teaspoon of salt per litre of water, assist the child to drink it. Even if the child recovers quickly, ensure that s/he is referred to the doctor. If the child’s responses deteriorate then refer for medical care immediately. Monitor and record all vital signs – the level of response, the pulse and breathing rate and be prepared to give rescue breaths and chest compressions if necessary.12

Inward and upward thrust to the upper abdomen to dislodge the foreign body; this needs to be demonstrated during the training

11

This should be taught as part of Primary Trauma Care training

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(e) Animal Bites and Insect Stings Animal Bites: The first-aider should first find out what animal bite it is. First-aid: Minor bite - Wash the wound gently with soap and water; apply pressure with a clean towel or gauze to the injured area to stop any bleeding; apply antibiotic ointment to the area; apply a sterile bandage to the wound. Keep the injury elevated above the level of the heart if possible for few minutes to slow swelling. Refer the child for medical intervention if the wound is deep and gaping; if the child has been bitten by an unvaccinated dog (for anti-rabies shots) or if it is a snake bite. Insect stings: Usually stings from bees, wasps and hornets are not serious and are more painful than dangerous. But with any insect bite or sting it is important to look for signs of an allergic reaction. The first aider should try to relieve any swelling and pain and arrange any medical treatment, if necessary. First-aid: The first-aider needs to reassure and calm the child down. There will be pain and possibly some redness and swelling around the site of the sting. If the sting is visible, brush or scrape it off. The first-aider could use the blunt edge of a knife. Tweezers should be avoided as it increases the risk of squeezing more poison into the wound. Apply an ice pack or cold compress for at least 10 minutes, and if possible raise the affected part. If swelling and pain persist the child should be referred to a hospital. Stings to the mouth and throat can be dangerous. There is a risk of the tissues in the mouth and throat swelling which could cause the airway to become blocked. Sucking on an ice cube, an ice cream or lolly or sipping cold water will prevent any swelling. However, if the swelling starts to develop and breathing becomes difficult then arrange for medical help immediately. Some people suffer severe allergic reactions to insect bites and stings. If the child shows any sign of impaired breathing or swelling to the face, neck, tongue, mouth or lips or shows a wide spread rash then call for medical help. (f)

Allergic Reactions (Anaphylaxis)

A severe allergic reaction will affect the whole body; in susceptible individuals it may develop within seconds or minutes of contact with the trigger factor and is potentially fatal. Possible triggers can include skin or airborne contact with particular materials, the injection of a specific drug, the sting of a certain insect or the ingestion of food such as peanuts. Recognition: Impaired breathing - this may range from a tight chest to severe difficulty; there may be a wheeze or the child might actually gasp for air; signs of shock; widespread blotchy skin eruption; swelling of the tongue and throat; puffiness around the eyes; or anxiety. 43


Emergency drugs have been suggested in the formulary for anaphylaxis [see Annexure 2(ii)]. Their use should be under the care of the doctor. If the doctor cannot be immediately available, emergency services must be called in or the child should be rushed to the nearest hospital. (g) Seizures A seizure - also called a convulsion or fit - consists of involuntary contractions of many muscles in the body. Epileptic seizures are due to recurrent, major disturbances of brain activity. These seizures can be sudden and dramatic. Just before a seizure, a child may have a brief warning period (aura) with, for example, a strange feeling or a special smell or taste. No matter what the cause of the seizure, care must always include maintaining an open, clear airway and monitoring the child’s vital signs - level of response, pulse and breathing. You will also need to protect the child from further harm during a seizure and arrange appropriate aftercare once they have recovered. First-aid: Initial efforts should be directed at protecting the child from additionally injuring himself or herself. If the child is standing or sitting, gently lower to the ground to avoid a fall. Nothing should be placed in the child’s mouth. Place on one side to prevent choking on secretions and blockage of airway by the tongue. Loosen restrictive clothing. If possible, place a cushion or blanket under the child’s head. Do not hold or restrain the child; clear the area around to prevent injury from sharp objects; do not give food, drink, or medications during a seizure; remain with the child during the seizure to monitor progress. Observe all activity during the seizure, including: time the seizure began; area of the body where seizure began; any movement of the seizure from one area of the body to the other. When the seizure is over: If necessary, clear secretions from the mouth. Keep on one side to allow for drainage of secretions; monitor breathing; determine level of awareness; determine individual’s ability to move arms and legs; provide privacy; check for loss of control of urine and stool and check for injuries. If the individual remains unconscious after the seizure is over, refer immediately to a hospital. Keep the individual comfortable; allow the individual to sleep as needed (sleep may last from 30 minutes to several hours) and record the length of the seizure and activity during and after the seizure. (h) Poisoning Poisoning is common in suicide attempts and can also occur due to the result of an accident. The first-aider needs to identify the type of poison and the way it has entered the body – by ingestion, by inhaling, or absorption and then provide first-aid and immediately call for medical help.

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Ingested Poison is one that is introduced in the digestive tract by way of mouth. It could also be a case of food poisoning. Recognition: This would include altered mental state, burns around the mouth, nausea and vomiting, abdominal pain and diarrhoea. First-aid: First-aider should try and identify the poison, place the child on its left side, save any vomitus and keep it with the child and seek immediate medical help. The first-aider should not induce vomiting if the child is unresponsive or if the child has ingested acid, a petroleum product or furniture polish. Inhaled Poison is a poison breathed into the lungs. Recognition: The child may have a history of inhaling drugs, there would be breathing difficulty, chest pain, hoarse cough, burning sensation in the throat, cyanosis (bluish discolouration of skin and mucous membrane), dizziness, headache and seizures. First-aid: Remove the child from the toxic environment and into fresh air immediately and seek medical attention. Absorbed Poison also known as contact poison, enters the body through the skin. Recognition: There could be liquid or powder on the skin, burns, itching and irritation, redness, rashes and blisters. First-aid: The first-aider should remove the clothes of the child and with a dry cloth blot the poison from the skin. If the poison is a dry powder it could be brushed off. The area can be flooded with a large amount of water. Introduction to Common Childhood Illnesses There are some illnesses that are common amongst children in institutions and it is important that they are identified early and that measures are taken at the primary level to manage them. Children in the age group under consideration are usually able to refer themselves if they are feeling unwell or facing a problem. However, it is good to recognise warning signs (symptoms13) of illness or disease and take early measures to ensure that the child is well looked after. These include: „„Unusual

lethargy „„Lack of appetite „„Pain „„Fever „„Cough „„Vomiting Signs are what the health worker / doctor finds, symptoms are the complaints made by the patient

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Some symptoms that are more serious and warrant a quick referral to a doctor include: „„Semi

or un-consciousness „„Any abnormal behaviour „„Weight loss „„Bleeding from anywhere, not related to injury (in cough, vomit, urine, stool, or from the gums) „„High fever (over 39 degrees Celsius) „„Any fever not improving in a few days and ALL fevers over 7 days „„Fever with bruising „„Fever with neck stiffness „„Fever with chills and rigour (shivering) „„Breathlessness or difficulty in breathing „„Severe abdominal pain unrelieved by routine analgesics „„Severe uncontrollable vomiting „„Seizures (fits) Before we begin to describe some common illnesses, we need to make a note of the following: „„A

child who keeps presenting with non-specific symptoms: Many children come with recurring symptoms like pain in the stomach, weakness and body ache. Even after being examined thoroughly sometimes nothing specific can be found. Dealing with such children who keep coming up with the same symptoms or many different symptoms again and again despite assurances from the doctor that ‘there is nothing wrong’ is a challenge for both doctors and health workers. The first thing is to take the child seriously at each such occasion and make sure that one is not missing any serious physical problem. Thus the list of symptoms suggesting severity continues to apply. It is also recommended that at least one round of investigations be done depending on the symptoms, such as an ultrasound abdomen for recurrent pain in the abdomen. We may find a specific cause that would otherwise have been missed. „„It would be a huge mistake to label a child as a ‘malingerer’ (pretending to be unwell) even if there is no physical problem. The fact is that the child actually feels unwell or pain even though we think there is nothing physically wrong and nothing specific has been found as a cause. We must accept that the child needs care and is expressing being unwell even if it is not a medical problem. Such children must be reassured, given relief depending on the severity of the complaint and provided with extra attention on a one-to-one basis with patience and concern. Sometimes placebos (such as multivitamin tablets) may need to be prescribed by the doctor.

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The child is approaching the health worker as a plea for attention and help, and this must be immediately made available. A counsellor’s help should be taken. „„Thus the take home message for such children is – take each episode seriously. A child who keeps complaining of abdominal pain and has been labelled as ‘nothing wrong with him/her’ may come up with appendicitis, which can get missed. In any case, never belittle the symptoms or dismiss them. „„Home remedies – In many common illnesses, home remedies work especially for seasonal fever, cold-cough, stomach related problems, anaemia, skin infections and so on. Home remedies from herbs, fruits, vegetables, etc. can be very beneficial and health workers may receive separate training on the same. These can be started immediately. The home could have a small area where some basic herbs could be grown.14 Now we will describe some common illnesses with the point of view of management at the primary level as well as recognition of danger signs for referral and prevention. Please note that the list of serious signs/symptoms above applies to all the conditions being described below. (a) Fever Fever has a variety of causes; from minor infections like cold and coughs described below to very serious conditions like meningitis, and it requires experience and training to make a specific diagnosis of the cause. If fever is accompanied with any danger signs listed above the child must be referred to a doctor for further management. How to identify: Fever is usually reported by the child, a friend or care giver. It MUST be measured by a thermometer, confirmed and recorded before taking action. What to do: If the fever is high and causing discomfort Paracetamol should be given (see table 3 for dose and frequency). If it does not come down with medication, sponging with tepid water (water at body temperature, not cold) should be done. Specific danger signs; when to refer: As listed in the section above. Prevention: This too depends on the specific cause of the fever and will be described in sections below. (b) Cold and Coughs Cold and coughs are common, frequent and minor problems amongst groups of children living together. How to identify: These are recognised by the fact that the nose may be blocked or runny with a clear discharge. The child may sneeze, cough and may also have some vomiting or The Chhattisgarh Government published a detailed module on ‘treatment of common illnesses through home remedies/ herbs (Jadi Buti le kare ilaaj). This was brought out under the Mitanin programme.

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diarrhoea and mild fever. The child is usually well in her/himself and able to continue with daily activities though s/he may be a little more tired than usual or eat less. What to do: These are usually viral in nature and require little more than rest and plenty of fluids. Paracetamol may be given if the fever is high or is causing the child discomfort or if there is body ache. The body fights off the infection with its own immunity and antibiotics usually have no role in colds and coughs. The nasal passages may be kept clear by using saline nasal drops (see table 3 for instructions on making saline solution) frequently. This will allow the child to breathe, eat and sleep with ease. Cough syrups and anti-allergic tablets need not be prescribed routinely. These cause drowsiness. However, if there is too much sneezing or cough, a tablet of Cetirizine may be required. Specific danger signs; when to refer: If there is high fever, the child looks unwell even if the fever is down, the sputum is yellow, there is breathing difficulty, or if the fever has continued for over five days and is not getting better. Prevention: These are spread through air and close contact. Prevention includes good personal care, clean environment and nutrition and keeping the ailing child away from other children. (c) Meningitis Meningitis is a very serious infectious disease affecting the brain. How to identify: The symptoms are fever, headache, lethargy, altered consciousness, convulsions, neck stiffness, forceful vomiting, and rashes â&#x20AC;&#x201C; especially bruise-like rashes. What to do: If meningitis is suspected the child must immediately be taken to hospital and treated there till s/he is well. Prevention: The measures for prevention include vaccination and antibiotics for those who have come in contact and will be suggested by the doctor in charge. (d) Measles Measles is a highly infectious viral disease. How to identify: Measles is suggested by fever along with a characteristic rash. The first few days of fever may be accompanied by a runny nose, cough and redness of the eyes. The rash is a dusky-red fine rash that starts over the head and face and spreads over the whole body proceeding downwards. It is not itchy. The fever subsides in two-three days after the onset of rash and the rash also starts fading a few days after it spreads. What to do: Rest and plenty of fluids. Paracetamol should be given if necessary for fever. Specific danger signs; when to refer: If there is earache, diarrhoea, difficulty in breathing, child becomes unwell again after showing signs of recovery, or if there is any change in consciousness. 48


Prevention: The measures for prevention include vaccination and keeping the sick child away from others for four days after the onset of rash as it spreads through close contact. (e) Chicken Pox Chicken pox is a highly infectious viral disease. How to identify: Like measles it is suggested by fever along with a characteristic rash. The rash accompanies the fever and begins on the trunk spreading later to the head and face. It is intensely itchy, starting as red spots and becoming pearly in colour at the centre. The rash goes through ulceration, crusting and healing over three or four days. What to do: Rest and plenty of fluids. Paracetamol should be given if necessary for fever. The itching is relieved by cool baths and lacto calamine lotion. Scratching will result in scarring and should be discouraged. Specific danger signs; when to refer: The disease is usually mild in nature and does not often result in anything serious. The list of serious signs remains as given in the beginning of this section. Prevention: There is a vaccine for chicken pox but it is not routinely prescribed. Keeping the child away from others till all the scabs have fallen off will prevent it from spreading. (f)

Malaria

Malaria is caused by the bite of a mosquito carrying the causative organism. How to identify: Any fever can be due to malaria. However, typically malaria is suggested by high fever that comes and goes, with chills, rigour and sweating, nausea and headache. What to do: Malaria requires specific treatment with anti-malarials under the care of a doctor. Getting a blood test for malaria is very important if malaria is suspected. Meanwhile, the fever should be managed as given in the section on fevers [section (a)]. Specific danger signs; when to refer: The child may continue to be managed at home and not be hospitalised if the malaria is of the benign type (which will be known after the blood test). However, danger signs for referral are as in the list in the beginning of this section. Prevention: This does not spread from person to person. Prevention requires mosquito control measures like spraying and using repellents together with personal protection through insecticide treated bed nets and repellent creams. (g) Pneumonia Pneumonia is an infection of the lungs and can occur due to various organisms. How to identify: It is characterised by fever and difficulty in breathing/fast breathing. There is likely to be a cough also and the fever may be accompanied with chill.

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What to do: The child has to be treated under the care of the doctor with appropriate antibiotics. Fever management may be started as described above. Specific danger signs; when to refer: If the child does not get better even after two-three days of starting treatment, if the difficulty in breathing gets worse at any stage, or if the child is unable to take the medicines due to any reason (such as vomiting). Prevention: The spread is by close contact though the disease is not as infectious as measles or chicken pox. The child should be separated from others till well. (h) Tuberculosis (TB) TB is a special kind of chest infection (though it can affect any part of the body). A common form of TB in childhood is seen in the form of enlarged lymph glands in the neck area. How to identify: Any cough lasting over two weeks should lead to a suspicion of TB and be investigated under the care of a doctor. Similarly, any low grade fever for many days along with weight loss or any of the serious signs listed at the beginning of this section may turn out to be TB and need to be investigated by the doctor. Lumps in the neck area under the jaw or towards the side should also be investigated. What to do: The most important thing to do is to make sure that TB is either diagnosed or ruled out by the doctor. If it is TB, medicines will continue for at least 6 months. It is the health workersâ&#x20AC;&#x2122; duty to ensure that the medicine is being taken without any break. If the child has to go home in between it is imperative that the child is trained to take the medicines him/herself or an adult carer is entrusted with the task. Sufficient amounts of medicine to cover the entire duration of the childâ&#x20AC;&#x2122;s absence, and extra, must be sent with the child. Simultaneously the health worker must take care of the nutrition of the child and provide extra nutrition in the form of eggs and milk if necessary. The medicines may cause harmless side-effects such as reddening of sweat and urine, which should be explained to the child. Specific danger signs; when to refer: If the child does not get better even after two-three weeks of starting treatment, if there is difficulty in breathing at any stage, if the child is unable to take the medicines due to any reason (such as vomiting), or if there is jaundice. Prevention: Taking the BCG vaccine in early childhood prevents some forms of TB. Overcrowding and malnutrition further create conditions for TB. The best way to prevent the spread of TB is by identifying persons with the illness and getting them treated. The identified child need not be kept away from others nor do their utensils and clothes have to be separated at all. Close contacts should be screened for TB also under the instructions of the doctor. (i)

Asthma

Asthma is an allergic reaction of the airways that causes cough and difficulty in breathing. How to identify: If a child gets attacks of fast breathing, difficulty in breathing, tightness in 50


the chest or wheezing every now and then, asthma should be thought about. Asthma may also show up as a cough that happens during sleep or early morning. It may be triggered by a cold and cough in children or get worse in specific seasons such as spring. There could also be a family history of breathing problems. What to do: The asthma should be confirmed by a doctor and treated by her/him. The child and carers should be taught to use the medicines (inhalers with spacers are preferred) as soon as the attack starts even before seeing the doctor. Even if well, the child should be routinely under the care of a doctor in case the medicines need to be changed or increased. Growth should be monitored as well. Specific danger signs; when to refer: If the breathlessness is not relieved soon after medication or the child is getting worse even after inhaled medication, the child should be seen by a doctor. Prevention: Some medicines may be given for preventing attacks in some severe cases. Many children out grow their asthma as they grow older. Triggers can be prevented by keeping the rooms free of smoke and dampness and by dusting the mattresses frequently. Asthma is not passed on from person to person by contact. (j)

Diarrhoea

Diarrhoea is a symptom (not a disease in itself) manifested by the frequent passage of loose/watery stools. It can occur for a variety of reasons. It may be accompanied with vomiting (gastroenteritis) and/or fever. How to identify: Frequent passage of loose/watery stools. What to do: Most children recover within two-three days on their own without any specific treatment. The most important part of managing diarrhoea is to make sure that the child retains enough fluid to compensate for the loss through stools and to prevent dehydration. This is achieved by giving fluids very frequently, which could be WHO-ORS or home based fluids such as home made ORS or rice-water with salt (maand) as well as coconut water. The aim should be to ensure that the child passes enough urine. The child should get food to eat if s/he feels like it â&#x20AC;&#x201C; small frequent meals with low-fibre content, such as curd-rice, bread and jam, etc. Specific danger signs; when to refer: If the child is vomiting continuously, if the urine is getting very dark and concentrated or no urine has been passed at all for some hours, if there is high fever, if there is blood in the stools, or if there are other signs of dehydration such as sunken eyes, dry tongue and wrinkled skin. Children of this age group rarely need to be admitted for IV fluids unless they are suffering from some severe form of gastroenteritis like cholera. 51


Prevention: Personal hygiene and careful hand-washing during food preparation, after using the toilet and before eating. Also by maintaining food hygiene, water safety and proper sanitation (see section on housekeeping). (k) Typhoid Typhoid is an infectious disease spread through contaminated food and water. How to identify: It is characterised by prolonged high fever, nausea, severe fatigue and loss of appetite. A runny nose or any other symptoms of a common cold do not accompany the fever. Typhoid can only be diagnosed through blood tests and these would take place as a result of referral for the fever by the health worker. What to do: All children with typhoid must be under the regular care and follow up of a doctor. Most children with typhoid would continue to be treated in the home with antibiotics prescribed by the doctor for a period of two-three weeks. They need much nursing care to make sure they rest and continue to drink enough fluids and take small simple meals as soon as their appetite returns. Specific danger signs; when to refer: Inability to take medicines due to vomiting, abdominal pain, any change in the level of consciousness. Prevention: Personal hygiene and careful hand-washing during food preparation, after using the toilet and before eating. Maintaining food hygiene, water safety and proper sanitation is critical. Typhoid vaccination is recommended. It is important to investigate the source of the typhoid bacteria and thus food handlers should have their stool and urine tested for carrier status and then treated accordingly to prevent further spread. (l)

Jaundice

Jaundice, like diarrhoea or cough, is a sign, not a disease in itself and can have many different causes. A common and mild cause of jaundice is a form of hepatitis that is spread through food and water (Hepatitis A and E). How to identify: The white part of the eyes becomes yellowish. The urine also turns dark yellow. The stools may be chalky in colour. The child may also have fever, nausea, vomiting and loss of appetite. What to do: All children with jaundice must be under the care of a doctor and be investigated for the cause of the jaundice. Treatment will depend upon the cause. Children with Hepatitis A or E will require care similar to that in typhoid. No antibiotics are prescribed since it is a viral illness. It will take over a month for full recovery. Specific danger signs; when to refer: Abdominal pain, any change in the level of consciousness, or bleeding from anywhere.

52


Prevention: Hygiene and careful hand-washing during food preparation, after using the toilet and before eating. Maintaining food safety, water safety and proper sanitation is critical. Hepatitis A vaccine is available and can be considered though it is expensive and the disease is generally considered mild. (m) Epilepsy Epilepsy is a neurological problem characterised by ‘seizures’ or ‘fits’, which are sudden episodes of brief, repetitive abnormal movements or behaviour along with change in consciousness (mental state). The child usually remains normal between such seizures. How to identify: Seizures are generally noted by care givers or teachers. They may note periods of inattention in class (characterised by a blank gaze) or full-fledged loss of consciousness with jerky movements of all or some limbs. What to do: All children with seizures must be referred to a doctor and investigated. Once the doctor prescribes treatment, the health worker must ensure that the child is taking the treatment regularly. Other precautions include advising the child not to swim, climb heights or lock the bathroom door. Otherwise the child should be able to lead a normal life. All care givers, including parents and teachers, must know about the child’s condition and how to manage a seizure if it occurs (see section on First-aid and Emergencies). Specific danger signs; when to refer: If the seizures occur despite treatment the doctor must be informed. If any abnormalities persist even after the seizure is over or if the seizures are getting more prolonged, the child must be referred. Drugs may cause side effects like jaundice and the health worker should be alert to those. Prevention: There is no specific prevention. However, taking the medicine regularly is the best form of preventing seizures. Some children are able to identify triggers for seizures such as watching TV or lack of sleep and these should be avoided. (n) Scabies There are many different causes for skin problems to occur including allergic reactions and infections such as fungal. Scabies is a special kind of infection that is very infectious and spreads though direct contact from person to person. How to identify: Severe itching with a rash with crusting, especially in the web spaces of the fingers and toes, groin and underarms. What to do: Overnight application of gamma benzene hydrochloride or Permethrin over the entire body from neck downwards after a thorough scrub bath. The care givers and close contacts should also be treated simultaneously. The clothes, bed linen, towels of the child should be boiled (washed in high heat). The child may need to be prescribed Cetirizine for itching if it is severe. 53


Specific danger signs; when to refer: The child should not generally need to be referred for scabies. Itching may persist for one to two weeks even after treatment. If it persists any longer or if new rashes come up, the child should be shown to the doctor. Prevention: Good personal hygiene needs to be discussed with the child and his/her family for scabies. (o) Lice A louse is an infestation of the hair with an insect and is also very contagious. How to identify: Lice cause itching of the scalp and nits (eggs) can often be seen over the hair close to the scalp. What to do: Wet combing with a fine-toothed comb and two applications of Permethrin one week apart. Care givers and close contacts should be treated simultaneously too. Specific danger signs; when to refer: The child may not need any referral. If itching still persists after treatment then the child should be shown to the doctor. Prevention: Prevention includes good personal hygiene. Close contacts should also be treated to prevent further spread.

54


Chapter

8

Drug Formulary

Drug Formulary The drug formulary is an essential component of any health programme since it is based upon the objectives, the type of personnel available and the public health perspective of the programme. It is of great assistance to the practice of rational prescribing as well as to the logistics and management of the supply of drugs. The suggested formulary as shown in Table 3 is based on the experience of running health care clinics at the community level by various organisations, some of which have specially run services for children (see Annexure 2 (i) and (ii) for a detailed indicative formulary in use by Jan Swasthya Sahyog). Formularies used in government health worker programmes such as the ASHA programme and for the implementation of IMNCI have also been consulted. It has also been made after consulting available standard treatment guidelines and textbooks for drugs and dosages in children (see Bibliography for details). The formulary does not deny the doctor the right to make special prescriptions; it only details what will be regularly kept in stock. The formulary may change with specific local needs but this should be done after consultation with the Advisory Committee. It is preferable to use generics if they can be easily sourced (see Annexure 2(iii) for an indicative rate list and source).15 All drugs should be available in syrup form for children under five years. However, this formulary has been created keeping children over five years in mind. Extensive training is required for health workers on the use of drugs and their dosages if there is no doctor available to prescribe the medication. The health workers require extensive preliminary and refresher training as well as supportive materials for their aid. Health workers (and doctors) should be discouraged from prescribing from memory. List of Drugs to be made available at the home: In general, drugs that are permitted for health workers to prescribe without supervision have been marked with an asterisk in Table 3. This further gives the details of the purpose, dosage and frequency of drugs that can be administered by the health worker without supervision. A detailed description and dosage of other intravenous and oral drugs that can be prescribed only by medical doctors is attached in Annexure 2 (i) and Annexure 2(ii).

http://www.locostindia.com/pdf/pdf3.pdf

15

55


Table 3: Drug Formulary for Home S.No.

1.

List of Drugs to be available at the home *Antipyretics, Anti inflammatory and Analgesics16 Paracetamol

Purpose

Single Dosage (according to weight of the child)

Paracetamol 10-14 kg – ¼ tablet or - Fever, 7.5 ml Headaches, Joint 15-19 kg – ½ tablet or pain 10 ml

Frequency

4-6 hourly as required. Maximum 4 doses in 24 hrs

20-29 kg – ½ tablet

(500 mg tablet or syrup 125 mg available)

30-44 kg – 1 tablet 45 kg and above – 1 tablet

Ibuprofen

Ibuprofen – For (200 mg and 400 mg severe pain and tablets available) injuries

10-14 kg – ¼ of 200 mg 8 hourly as required (not 15-19 kg – ½ of 200 mg to be used 20-29 kg – 1 tablet of if dengue is 200 mg suspected). Maximum 3 30-44 kg – 1 tablet of doses in 24 hrs 400 mg 45 kg and above – 1 tablet of 400 mg

2.

*Antiallergics Chlorpheniramine maleate (causes sedation)

Any allergic reaction

*Antacids Aluminium Hydroxide + Magnesium Trisilicate

16

15-19 kg – ½ tablet 20-29 kg – ½ tablet 45 kg and above – 1 tablet

For gas, acidity related stomach cramps – upper abdominal pain

Antacid syrup 1-2 tsp or 1 tablet (to be chewed)

Please note that Nimuselide has been banned for use in children

56

8 hourly as required. Maximum 3 doses in 24 hrs

30-44 kg – 1 tablet

(4 mg tablet or syrup 2 mg/5 ml available)

3.

10-14 kg – 4 ml

When the pain arises. Maximum 3 doses in 24 hrs


4.

*Anti spasmodic Dicyclomine hydrochloride (20 mg tablets available)

5.

*Antiemetics Domperidone

For gastrointestinal disorder and to prevent spasms

For vomiting / nausea

10-14 kg – ¼ tablet 15-19 kg – ¼ tablet 20-29 kg – ½ tablet 30-44 kg – 1 tablet 45 kg and above – 1 tablet Children 3-7 years: 5 mg i.e. ½ tablet per dose Children 8-12 years: 10 mg i.e. 1 tablet per dose

6.

Antibiotics Cotrimoxazole Amoxicillin Ciprofloxacin

8 hourly as required. Maximum 3 doses in 24 hrs

8 hourly as required. Maximum 3 doses in 24 hrs

Not to be given by health worker without prescription

Nalidixic acid 7.

Metronidazole *Anthelminthics Albendazole

8.

*Antimalarials Chloroquine17 (150 mg tablet or syrup 50 mg/5 ml available)

Activity against intestinal and tissue parasites

To treat malaria

400 mg (two 200 mg tablets) or 20 ml (400 mg) of suspension as a single dose in both adults and children over two years of age. Three day dose:

Once every 6 months

10-14 kg – 15 ml syrup on day 1 and day 2; 7.5 ml syrup on day 3 15-19 kg – 1 ½ tablet on day 1 and 1 tablet on day 2 and day 3 20-29 kg – 1 ½ tablet on day 1 and 2 and 1 tablet on day 3 30-44 kg – 3 tablets on day 1 and 2 and 2 tablets on day 3 45 kg and above – 4 tablets on day 1 and 2 and 2 tablets on day 3

In different geographical areas, this may need to be modified / expanded according to protocols for that area

17

57


9.

*Bronchodilators

Anti-asthma

Salbutamol –

*Iron and vitamins Ferrous sulphate

20-29 kg –1- 1 ½ tablet 30-44 kg – 2 tablets 45 kg and above – 2 tablets Iron – for mild to 10-14 kg – ½ tablet or severe anaemia 6 ml syrup 15-19 kg – ½ tablet

(60 mg tablet or 6 mg iron/ml syrup available)

20-29 kg – 1 tablet 30-44 kg – 1 tablets 45 kg and above – 1 tablet

11.

Drugs for local use Miconazole cream *Gentamicin eye drops *Ciprofloxacin eye drops *Gentian Violet solution

Thrice a day

15-19 kg – 1 tablet

(4 mg tablet or syrup 2mg/5ml plus inhaler with spacer available)

10.

10-14 kg – 5ml or ½ tablet

For fungal skin infections Eye infection

For minor cuts/ fungal infection For scabies

*Permethrin/Gamma Benzene lotion

For 10-19 kg single dose in 24 hrs. Over 20 kg two tablets in 24 hours and in case of severe anaemia in grown up children 3 tablets.

Local application

Twice a day till infection clears

1 drop each eye

Twice a day for five days

For scabies, overnight application of gamma benzene hydrochloride or Permethrin over the entire body from neck downwards after a thorough scrub bath. (Leave on for 12 hours minimum.)

For lice

For skin Clobetasone butyrate infections/ / Betamethasone eczema dipropionate

58

For lice, wet comb with a fine toothed comb and apply Permethrin.

One application to scalp per week for two weeks


12.

Emergency Drugs Hydrocortisone inj Adrenaline inj (1:1000) Syringes

13. i

Salbutamol inhaler with spacer Others *ORS sachets (WHO approved)

ii. *Saline nasal drops

If ORS sachets not available then ORS can be prepared at the home – for one glass (200 ml) of water add a pinch of salt and a spoon of sugar or/ In one litre of water – 1 tsp of salt and 8 tsp sugar. ORS fluids should be discarded after 24 hrs Saline nasal drops can be prepared – 250 ml of boiled water, halfteaspoon salt

Can be given frequently

Can be used frequently. Before meals and naps.

iii. *Thermometer Torch Weighing machine Tape measure

59


Chapter

9

Human Resource: Structure, Roles, Responsibilities and Monitoring Mechanisms

Human Resources To facilitate the smooth functioning of the health plan at the home a cross section of people are required. Fig. 3 illustrates this set-up. Structure All homes will have health workers assigned to look after the health needs of the children. However the other staff members like the home coordinator and house mothers are equally responsible for addressing these health needs as well. The staff at the home is supported by a panel of doctors that must include a counsellor and if possible an AYUSH specialist as well. The home must have tie-ups with a nearby government hospital where the children needing referrals and hospitalisation can be taken. The staff must also be aware of government sponsored health programmes in order to avail of them as and when required. An Advisory Committee monitors all these efforts.

Fig. 3 â&#x20AC;&#x201C; Structure of Human Resources 60


Roles and Responsibilities The health programme of any home should be health worker centric. Nevertheless, a comprehensive view of the health system needs to be built amongst the entire staff. There should be adequate staff at the home (health worker, teachers, housemothers and housebrothers) to ensure that the health plan adopted can be suitably executed. It is important to rationalise work amongst them but the roles and responsibilities of every staff member cannot have defined boundaries since these may need to overlap. There should be flexible boundaries and in the absence of one staff member, the other should be able to fill in the gap. Some of these responsibilities however should be designated specifically for the health workers as they have more training and a greater role to play in the implementation of the health programme. (a) Health worker The health worker has a very important role to play at the home and is central to the health programme of the home. ‰‰ Ideally

there should be two designated health workers in every home who are responsible for providing primary level care. However, they may also fulfil other roles. ‰‰ The health worker will play a central role in the health assessment of the child, making the health plan, implementing that plan and reviewing the health of every child who enters the home. ‰‰ The health worker should ensure proper first aid in cases of accidents, burns, and epilepsy before referral/escorting to a medical facility. ‰‰ The health worker has to effectively handle emergency cases that need immediate medical attention and cases of infectious diseases (tuberculosis, diarrhoea, chicken pox) at the level of the home and then decide on referrals on a case-by-case basis. ‰‰ The health worker should provide treatment for moderate illnesses (like diarrhoea) and watch for early signs of deterioration and refer if necessary. ‰‰ The health worker should be able to facilitate early detection of serious chronic illnesses (like TB) and refer if necessary. ‰‰ Give special attention to malnourished children. ‰‰ The health worker must call meetings with the panel of doctors once in six months where the health status of all the children should be reviewed. ‰‰ The health worker needs to document and maintain health records. ‰‰ The health worker along with other staff members must follow routine health interventions such as immunisation, de-worming and iron supplementation (see Table 4). 61


‰‰ The

health worker will be the depot holder for common health care commodities and should ensure that the drugs suggested in the formulary are available at any given time. Care should be taken to keep them away from the reach of the children. ‰‰ Be aware of the list of essential drugs available at the primary level that can be administered and use only medicines and care advised in the programme. They should also be aware of the side effects of the drugs used. ‰‰ Maintaining drug stock registers is an important activity of the health workers. ‰‰ They need to carry out a monthly stock taking of drugs. This will ensure the timely replenishing of stocks. ‰‰ The health workers also need to note the expiry date of medicines as and when they come to the home to make sure that expired medicines are discarded and fresh stock is procured. ‰‰ The health workers must be able to operate the equipment available at the home and also check it once a month to see that it is correctly calibrated. ‰‰ Ask for help when necessary from other staff members and the attending doctor. ‰‰ Make formal links with government hospitals in the vicinity for referrals. Links should also be there with the PSM department of government hospitals. Table 4: Routine health interventions by the health worker No.

Intervention

Intervals

1

De-worming

During admission and every 6 monthly

2

Iron (with Folic Acid)

At admission for 3 months

3

Immunisation

MMR Typhoid (3 yearly) Tetanus (0, 1, 6 months) Hepatitis B (0, 1, 2 months) 6 monthly charting of weight, height and if malnourished then monthly charting of weight

4

Anthropometry

5

Health checks/dental/eye checks Once a year for every child

6

Drill on hygiene of every child and the home

62

Daily


(b) House mothers ‰‰ Depending

on the number of house mothers in a home, the responsibility of a specific group of children would be assigned to them. ‰‰ With respect to the health of a child, she should look after the overall well-being and happiness of the child and his/her needs and report to the appropriate staff if she is unable to handle it at her level. ‰‰ The health worker and the house mother need to monitor hygiene (hair, nails, skin) of every child on a daily basis. They should note whether clothes are being washed regularly. ‰‰ If a child is ill, the house mother must report this to the health worker. ‰‰ If the health worker gives instructions to the house mother for the care of a sick child it should be followed up by the house mother. (c) Home coordinator ‰‰ The

co-ordinator has an important role to play in seeing that all the health systems in the home are functioning smoothly. ‰‰ The co-ordinator therefore, has an important role in monitoring the workings of all systems with the help and coordination of the other staff members. ‰‰ On arrival, the home co-ordinator should ensure that each child should be given a welcome kit including – a comb, toothbrush, a bar of soap, a towel and at least two sets of clothes. Every child must have his/her own locker, mattress, two bed sheets and one quilt for the winter season. ‰‰ The co-ordinator should be able to assess programmatic trends and bottlenecks and offer appropriate suggestions. S/he will also be responsible for overall surveillance. ‰‰ For post-surgery care of a child, the home-coordinator must ensure that there is a 24-hour attendee with the child. (d) Panel of doctors panel of doctors/health professionals comprising of a medical doctor (paediatrician), ENT specialist, dentist, ophthalmologist, skin specialist, gynaecologist and counsellor/psychotherapist should be available. ‰‰ Protocols for the paediatrician’s visits must be specified. The paediatrician must be available during health assessments, making of the health plan of new entrants and during the review of all children. The paediatrician, if and when needed, must also record referrals, so that the health worker can follow it up. ‰‰ The paediatrician could make a visit to the home once in 6 months for a general check up and a health review of the children. But the paediatrician must make one visit every month to assess and review cases that need ‰‰ A

63


medical attention, provide referral slips for those children who need medical attention from the given panel of doctors/hospitals and play a significant role in the on-going training and supportive supervision of the health workers. Monitoring Mechanisms It is important to have monitoring mechanisms in place that look at all operational aspects of the health programme. The Home Co-ordinator must monitor the functioning of the home on an everyday basis. For the success of the health programme s/he should: „„Monitor

all services related to the home – water, sanitation, and cleanliness of the home. „„Be conscious of the number of children who need medical attention on a given day and the decisions taken around it. „„Be watchful that the daily drill examining every child is taking place and that all other systems put in place are being adhered to. „„Be aware of documents and health records being kept by the health worker and ensure that they are updated as well as follow-up the implementation of the health plans. „„Hold meetings between health workers, house mothers and other staff members once a week to look into the operational issues of the health programme and take necessary steps to resolve any problems. „„These meetings should also review the files of children with an on-going medical problem and refer to the attending physician if necessary. Quality Issues Ensuring quality in a health programme would entail proper functioning of all health systems. There should be quality protocols maintained in training, curative services, health education, food, water, and general hygiene of the home. Evaluations should be conducted on the knowledge levels of the staff at the home. Feedback needs to be taken from the children at regular intervals on all health related systems available to them at the home and outside. Role of the Advisory Committee As discussed previously the Advisory Committee provides an overview of all the functions discussed above. It also plays a key role in maintaining and setting the policy for the health programme. The Advisory Committee should meet at least twice a year to receive a report and plan for the future.

64


Chapter

10

Training and Capacity Building

Training and Capacity Building of the Staff Health workers who are recruited should have had considerable experience in handling child health issues at the community level. It is recommended that they have at least finished 12th standard to be able to fill records adequately. All other staff too needs an orientation towards understanding health needs of a homeless child. On entering the home health workers need to go for induction training. Health workers need to develop technical capacities/skills so that there is not much reliance on a doctor for minor day-to-day problems. There will be a need for on-going training. This could be in the form of re-training and/or building capacities and skills. General Principles for Training for the Health Programme Since it is clear from the preceding sections that the health worker plays a key role in maintaining the health of the children in the home, the capacities of the health worker are critically important. Adequate training to build all the three components namely knowledge, attitude and skills, as well as post-training supportive supervision is necessary. Training should be scheduled as an induction course to cover the minimum package of competencies, monthly orientations on related health topics, which can be combined with the monthly coordination meeting and periodic refresher training. All trainings should ideally include a pre and post training assessment for evaluating learning. Since the trainings are dealing with adults, they should be highly participatory and participants should be allowed to air their experiences. This is also critical to be able to act on existing biases and preconceived notions before they embark upon the care of children who may be especially vulnerable both physically and emotionally. „„The training must include hands-on exercises, specially relating to early identification,

danger signs and use of drugs. „„Certain cross-cutting issues such as violence, gender sensitivity, sexuality, understanding Right to Consent and Privacy, etc should be covered sensitively by experienced trainers along with the more medical aspects of the training. „„Each issue must be dealt with using the following approach: i. General information about the topic ii. Special relationship with health of street children iii. How to prevent (root causes) iv. Early identification v. Primary level care at the level of the health worker (including quarantine if required) 65


vi. Danger signs and when to refer vii. How to follow up „„All training must be supported by printed material in appropriate and easy language with pictorial representations, algorithms, flow charts, etc. Much of this material is available from existing health worker programmes such as the ASHA and Mitanin programme though they are focused on children under the age of five. It is critical that all members of the coordination team who are expected to supervise also attend the full training at least once. They should also be involved with conducting the training as far as possible according to their abilities. This is to ensure that they perceive their role in maintenance of the quality of the programme and not look at themselves merely as administrators. (a) The Induction Training It is suggested that the minimum time requirement for this is six full days of residential training (see Box 7). This should include the following topics: ‰‰ Understanding

health and well-being: the public health perspective – the systemic and social determinants view, concept of well-being/life-cycle approach, the culture of the programme. ‰‰ Understanding issues in child health especially of street children together with issues relating to gender and sexuality18, and violence. ‰‰ The role of a health worker and overview of desired attitudes and tasks of a health worker. ‰‰ Specific training should include: (i) Dealing with a sick child w Early diagnosis, treatment, follow up w Special reference to danger signs (ii) Emergency Care (Primary Trauma Care) (iii) First-Aid - Basic Training on the anatomy and functions of the human body and then situations that need first-aid. (iv) Dealing with Epidemics (v) Knowledge on relevant Immunisations (vi) Knowledge of Drugs and handling medicines/drugs (one full day with practical sessions)

This can be merely introduced here and dealt with later in the monthly special sessions in further detail

18

66


(vii) Training on Equipment use – Thermometer, Height and Weight instruments (how to record temperature height and weight). (viii) Nutrition and Growth monitoring and dealing with mild, moderate and severely malnourished children. (ix) Use of referral services (when to make referrals) – panel of doctors and hospitals/dispensaries. (x) Common Dental and Eye problems and how to organise check ups. (xi) Training on documenting and record keeping – what is relevant, why is it relevant, what data needs to be analysed and how to analyse data. (xii) Conducting the daily inspection (see Box 8). Box 8: Daily Inspection Drill Checklist Daily Inspection Drill Checklist 1.

Children a) Sick / Unhappy Child b) Nails c) Overall hygiene

2.

Kitchen a) Hand washing facilities b) Utensils c) Food safety d) Nails e) Hair nets

3.

Toilets a. Hand washing facility b. Flush c. Sanitary napkin disposal

4. Garbage Disposal areas

67


Table 5: Induction training schedule - Six days residential training Days

Session 1 (9:00 – 11:00 Session 2 (11:30- Session 3 (2:00 – Session 4 (4:30 am) 1:00 pm) 4:00 pm) – 6:30pm)

Day 1

Welcome, Introduction and Understanding Pre-test health and well-being; Culture of the Home and the Programme

Issues on child health and health needs specific to street children; Perspective building

The role of a health worker and overview of tasks of a health worker (Ethical issues that health worker needs to be aware of)

Day 2

Specific tasks: Dealing with a sick child, infections and use of referrals – general care and danger signs

Dealing with infectious/ communicable diseases (chicken pox, tuberculosis, malaria), skin infections

Dealing with communicable diseases and use of referrals – Exercises

Day 3

Dealing with emergencies: Continued First Aid and trauma care

Practical sessions

Practical sessions

Day 4

Nutrition and Growth monitoring

Practical session on how to monitor growth and required dietary allowances. Meal planning for the home

Knowledge of immunisations

Knowledge on dental and eye problems and organising camps

Day 5

Drugs and equipment handling

Continued

Practical session

Practical session

Day 6

Training on documenting and record keeping

Continued

Daily inspection Post-test and drill and checklist / Feedback Organising health, session dental and eye checks

68

Dealing with a sick child (fever, diarrhoea, colds and coughs, measles, chicken pox, pneumonia, TB, malaria, meningitis)


(b) Post – Induction Monthly Sessions with Disability (Training for Two half-days) w Knowledge on disability: The Indian Context and Common Disabilities in Children w Understanding disability, experiences and social attitudes towards it w Early identification, referral and dealing with disabilities at the home

‰‰ Dealing

and Nutrition (Training for Two half-days) w Nutrition and Meal Planning w Food safety, food preparation and food handling

‰‰ Food

of Home Remedies for common illnesses (Training for One half-day) ‰‰ Issues relating to Home Environment and other systems – (Training for One half-day) w Clean water and waste disposal, fumigation at intervals, space for playground ‰‰ Use

‰‰ Health

Education (issues that health workers and other staff need training on to take sessions for the children) – (Training for Three half-days) w Life skills that children need to acquire to cope with growing up years w Training on sex education – body mapping and overview of organs, menstruation, reproduction and reproductive health (STIs/RTIs/HIV/ AIDS), contraceptive knowledge w Personal care related issues w Substance abuse

Once a year there should be evaluation of and re-training for some of the important skills. The health workers could also prioritise the issues that they feel they need training or retraining on.

69


Chapter

11

Maintenance of Health Records and Documentation

Health assessments and maintenance of records are important to ensure prevention, early detection of health problems and planning for the health needs of the child. They are also important to get a consolidated overview of the health programme at the home. Maintaining records is an important task of the health worker. The health worker should ensure that all records are in place and should be aware of the importance of documenting. S/he would have received training on what records need to be maintained and how they need to be documented and analysed. Maintaining health records of every child is critical. •• ••

••

•• ••

Maintaining accurate health records is essential in providing quality care and protecting the health and safety of children. If health records are present it is easy to keep track of the child’s medical history; this can further be used to understand better the child’s current health status and progress. Children’s health records can help child care providers identify preventive health needs such as immunisations or dental care and prepare a special care plan for children with chronic health conditions or special health needs such as asthma, diabetes, HIV/ AIDS or cancer. Growth monitoring records of every child helps keep track of the levels of malnourishment and the number of children who need special care and diet. As there are many children in the home it becomes physically difficult to remember individual details; therefore having group records makes it simpler.

Records and Registers (a) Records The following records need to be maintained: ‰‰ Every

child should have an individual file to his/her name – This will have the Health Assessment Form (Annexure 1 (i)), the Health Plan drawn out for the child and time line of interventions (Annexure 1 (ii)). Subsequently all medical documents of the child and details of each medical intervention get attached in this file. ‰‰ The Health Plan - Yearlong Health Checklist will help give an overview of the general health of the child over the year at a glance.

70


(b) Registers While every child has an individual file, there are registers that need to be maintained with information of all children that helps to maintain health information systems at the home. These registers need to be updated regularly and formats should be simple so that anyone who reads it is able to know what the data is about. The data should be discussed at each of the coordination meetings so that appropriate action can be taken. ‰‰ Sick child register – This will record names of the children who need medical

attention, with the doctor’s remarks, medicines/diagnostics prescribed and referrals made. This register is important for handing over of responsibility from the day staff to the night staff in order to dispense medicine. This will also help in tracking the nature and quantum of illness being encountered at the home.

Any referrals made

Date of recovery (Y/N)

Day 5

Day 4

Day 3

Day 2

Day 1

Drugs to be dispensed (at what time)

Doctor’s diagnosis

Name of the Child

Date

Format for Sick child register:

‰‰ Health

Camp register – This register should contain the day and date of the camp for both eye and dental problems. Then it should note the names of those children who need treatment either at the primary level or in a hospital. Immunisation details will go in a separate immunisation register.

Format for Health Camp Register: Name of the Child

Dentist’s observations

Treatment

Referral if any

Name of the Child

Ophthalmologist’s obser- Treatment vation

Referral if any

71


‰‰ Growth

monitoring register –This data needs to be analysed for the prevalence of malnutrition amongst resident children (see Annexure 3: Z score charts). Every child will have a chart in his/her individual file but a separate register also needs to be maintained that has the consolidated growth indicator data for all the children. The format below gives the health worker one time information on growth monitoring indicators for a child when s/he enters the home. Children who have a status other than normal, need to be followed up closely after remedial actions have started to be taken. For the rest, growth monitoring can happen once in 6 months. In the register write the age, height and weight of the child. Then calculate the growth indicators by looking at the given chart/table (see the section on Growth Monitoring).

Format for Growth Monitoring Register: 1

2

3

4

5

6

7

8

Name Date Date Age in Height Weight BMI BMI for of the of years of the of the age child birth to the child Child (Normal/ month wasted/ (eg. 6 severely yrs 3 wasted) mts)

9 Weight for age (Normal/ underweight

10

11

Height Action for age to be (Normal/ taken stunted)

‰‰ Hospital

register – All children who are referred and need long term treatment and care will have their names listed here.

‰‰ Immunisation

and De-worming register – This will be a month-wise register with names of children who need immunisation/de-worming in a particular month. Targets for every month need to be noted from the health plan of every child, if possible at the beginning of the year. Names of new entrants can be added from the month they have joined. The health worker needs to look at the register on the first of every month and note on a chart the targets that need to be achieved that month.

72


Format for immunisation and De-worming Register: (This table is for a single month.) Date Gender Typhoid of Birth

Polio MMR Hepatitis B

Any other

Deworming

If achieved put a tick

Date of entry

Date

Name of the child

‰‰ Minutes

of Meetings register - A register needs to be maintained to record the minutes of meetings held on health education for children or any health-related training that has been conducted for the staff. ‰‰ Drug stock register - this should have the Name of the drug, Expiry date, How many at the start of the month, How many left at the end of the month. (c) Monthly Reports Monthly reports need to be generated to get an overview of the health condition of the home and children [see Annexure 1 (iii)]. Some indicators that need to be noted at the end of every month – Number of children ill, referred and follow ups done; number of children immunised; number of malnourished children and what interventions have been taken and what have been the improvements. The consolidated data also provides details on what measures are being taken to create a safe home environment for the children (water, sanitation, fumigation if done). Summary Analysing consolidated data such as achievements against targets gives an idea of performance and efficiency. Similarly the consolidated data on illnesses will give the epidemiological morbidity data of the children – prevalent illnesses at a given time. On the whole, the consolidated data helps to maintain and improve the programme from a public health perspective while the personal files help to ensure optimal care for the individual child.

73


Annexure Annexure 1(i) Health Record

gsYFk fjdkWMZ (To be filled by the health worker within the first month of the child’s entry to the home)

¼;g QkWeZ gsYFk odZj n~okjk cPps ds gkse esa izos’k ds igys eghus esa Hkjk tk;sxk½ Instructions: 1. Fill the form in the language you and the child are comfortable with. 2. Do not leave any question unanswered; write NA (not applicable) wherever necessary. 3. Avoid overwriting. 4. If the child is young and is not able to answer information should be taken from the field worker or the child’s parents.

funsZ’k 1- 2- 3- 4-

ftl Hkk"kk esa lgwfy;r gS QkWeZ dks mlesa HkjsA dksbZ iz'u [kkyh u NksM+sa( tgk¡ vko';d gS ogk¡ ;k *ykxw ugha* fy[ksaA mifjys[ku u djsaA vxj cPpk NksVk gS vkSj tokc ugha ns ikrk rks mlds ekrk&firk ;k fQYM odZj ls tkudkjh ysa

_______________________________________________________________________ Child UIN: cPps dk UIN uacj% Name of the Child; Alias (Capital Letters): uke vkSj miuke% Date of Birth/Age (as on…………): mez@tUe frfFk ¼----------------------- rkjh[k ij½%

74

Sex: fyax%


Brief history of the child’s health before coming to the home

gkse esa izos'k ls igys cPps dh LokLF; fLrfFk i)

Is there any physical disability?

Yes

No

D;k fdlh izdkj dh 'kkjhfjd fodykaxrk gS\

gk¡

If yes, please specify vxj gk¡ ¼Li"V djsa½ ___________________________________________________

ii)

Has the child been taking drugs? D;k cPpk u'kk djrk gS\

ugha

Yes gk¡

No ugha

If yes, specify the drug and frequency

vxj gk¡ rks fdl izdkj dk u'kk djrk gS] vkSj fdruh ckj ____________________________________________________________________ iii)

Does the child have any known health problems? D;k cPps dks dksbZ LoLF; lEcaf/kr leL;k,¡ gS\

Visible injuries

'kkjhfjd pksV Respiratory

'olu ra=k lEcaf/kr

Skin related

Sexual/Reproductive

Ropk lEcaf/kr

Eye problem

vk¡[k lEcaf/kr

;kSu@iztuu lEcaf/kr

Dental problem

nkar lEcaf/kr

iv)

Has the child ever been admitted to the hospital? If yes for what?

D;k cPpk dHkh vLirky esa HkrhZ gqvk gS\ vxj gk¡] rks fdl dkj.k ls\

v)

Has the child undergone any major surgery? If yes, give details?

D;k cPps dh dHkh 'kY;fpfdRlk gqbZ gS\ vxj gk¡] rks Li"V djsa

vi)

Does anyone in the child’s family have any of the following ailments?

D;k cPps ds ifjokj ds fdlh lnL; dks ;g chekfj;k¡ gSa\ Tuberculosis Vh- chHIV/AIDS ,p- bZ- oh@,M~l

75


Diabetes

Hemophilia

Others, specify ___________________

e/kqesg gheksQhfy;k vU; ¼Li"V djsa½ __________________

vii) Any history of known allergies

fdlh ,ythZ vkS"k/k dk o`Rrkar gS

viii) History of current medication

orZeku vkS"k/k dk o`Rrkar

ix)

Has the child faced physical abuse?

D;k cPps ds lkFk dHkh 'kkjhfjd 'kks"k.k gqvk gS\ gk¡

If yes, (specify details)

vxj gk¡ ¼Li"V djsa½ ___________________________________________________

__________________________________________________________________

x)

Has the child faced sexual abuse?

Yes

No

D;k cPps ds lkFk dHkh ;kSu 'kks"k.k gqvk gS\

gk¡

ugha

If yes, (specify details)

vxj gk¡ ¼Li"V djsa½ ___________________________________________________

__________________________________________________________________

2.

Child’s health status at the time of entry in the home

gkse esa izos'k ds ckn cPps dh LokLF; fLFkfr

i)

BMI for age, height for age and weight for age of the child (plot on the charts)

mez ds fy, ch-,e-vkbZ] mez ds fy, yEckbZ] mez ds fy, ot+u ¼pkVZ IykV djsa½ 76

Yes

No

ugha


Height (in cm)

Weight (i n kg)

gkse ct+u ¼lsaVhehVj esa½ ¼fdyksxzke esa½

Age of the child (in years and to the month)

cPps dh mez eghuksa vkSj o"ks± esa

BMI (in kg/m2)

ch-,e-vkbZ ¼fdyksxzke@ ehVj2½

BMI = weight in kilograms (kg/m2) (Height in meters)2

ch-,e-vkbZ = fdyksxzke esa ot+u ¼yEckbZ ehVj esa½2

Circle or tick the box where the child

cPpk tgk¡ gSa ml ckWDl ij vad yxk;sa

Z- Scores

t & Ldksj

Height for age (5-19 years)

BMI for age (5-19 years)

Weight for age (5-10 years)

mez ds fy, yEckbZ ¼5&19 o"kZ½

mez ds fy, ch-,e-vkbZ ¼5&19 o"kZ½

mez ds fy, ot+u ¼5&10 o"kZ½

Above 3

Obese

3 ls Åij

eksVkik

Above 2

Overweight

2 ls Åij

vf/kd ot+u

Above 1

Possible risk of overweight

1 ls Åij

vf/kd ot+u gksus dh lEHkkouk

0 (median)

0 ¼e/;LFk½ Below -1

-1 ls de Below -2

Stunted

Wasted

Underweight

-2 ls de

vfodflr

{k;

detk+sj

Below -3

Severely stunted

Severely wasted

Severely underweight

-3 ls de

cgqr vfodflr

cgqr {;

cgqr det+ksj

iii)

Is there need for intervention? (Write down the status from the above table)

D;k cPPks dks lgk;rk dh t+:jr gS\

iv)

Has the child received any Immunisation/De-worming?

D;k cPps dk igys Vhdkdj.k gqvk gS\

77


Immunization

Vhdkdj.k

Received (date Due Date if any or month specify) fu;r rkjh[k ¼;fn

izkIr ¼frfFk ;k eghu½

Typhoid

VkbZQksbM BCG

ch-lh-th Polio Vaccine

iksfy;ks MMR

,We-,We-vkj Tetanus

VsVul Hepatitis B

gsfiVkbZVl ch Deworming

Mh&oeZ Others

vU;

3.

Sexual/Reproductive Health

;kSu@iztuu LoLF;

78

dksbZ½

Not received

Unsure

ugha izkIr

vfuf'pr


i.)

Has the child been tested for any STD (Sexually Transmitted Disease)? If yes, what was the result?

D;k cPps dh ,l Vh Mh ds fy, tkap dh xbZ gS\ vxj gS] rks ifj.kke D;k Fkk\

ii.)

Has the child been tested for HIV? If yes, what was the result?

D;k cPps dh ,p-bZ-oh ds fy, tkap dh xbZ gS\ vxj gS] rks ifj.kke D;k Fkk\

iii.) In case of girls, has the child attained puberty?

If yes, is the menstrual flow normal in terms of regularity, flow, etc.

D;k cPps dk ;kSou vkjEHk gks pqdk gS\ ¼yM+fd;ksa ds fy,½

vxj gk¡] rks cgko vkSj vko`fRr esa dksbZ ijs'kkuh rks ugha gS\

Any other observations (as made by the health worker)

gsYFkodZj n~okjk fd;k x;k vU; voyksdu

79


First General Health check up

MkWDVj n~okjk cPps dh igyh tkap (This will be done by a physician at the time of child’s entry to the Home) ¼;g MkWDVj n~okjk eghus esa ,d ckj fd;k tk;sxk½

Date: ____________________

Doctor’s Name: _____________________

frfFk% _____________________

MkWDVj dk uke% ______________________

Physician’s Observations: MkWDVj dk voyksdu% Anaemia ¼jDrkYirk½ Pallor ¼ihykiu½ Lymph glands ¼yfldk xzafFk;ksa½ CNS ¼lh-,u-,l½ CVS ¼lh-oh-,l½ ENT ¼bZ-,u-Vh½ Respiratory ¼'olu ra=k½ Abdomen ¼isV½

80


Haemoglobin (Hb): ___________________

Blood Group: _________________

gseksXyksfcu ¼vsp~-ch½% ____________________

jDr lewg% ____________________

Any other observations:

vU; izs{k.k%

Treatment Advice:

mipkj dh lykg%

Action taken:

buds fy, D;k mik; fd;s x,% Referrals (if any, with reason):

fdlh vkSj MkWDVj dks fn[kkus dh lykg ¼dkj.k ds lkFk½% S.No. Øekad

Date frfFk

Presenting Problem leL;k

Advice lykg

81


General Health check up

MkWDVj n~okjk cPps dh tkap (This will be done once a month by a physician) ¼;g MkWDVj n~okjk eghus esa ,d ckj fd;k tk;sxk½

Full Name of the Child and Alias (Capital letters) _______________________________

cPps dk iwjk uke vkSj miuke% ________________________________________________ Date: ________________

Doctor’s Name: ____________________

frfFk% ________________

MkWDVj dk uke% ____________________

Physician’s Observations:

MkWDVj dk voyksdu% Treatment Advice:

mipkj dh lykg% Action taken:

buds fy, D;k mik; fd;s x,% Referrals (if any, with reason):

fdlh vkSj MkWDVj dks fn[kus dh lykg ¼dkj.k ds lkFk½% _______________________________________________________________________ Date: ________________

Doctor’s Name: ____________________

frfFk% ________________

MkWDVj dk uke% ____________________

Physician’s Observations:

MkWDVj dk voyksdu% Treatment Advice:

mipkj dh lykg% Action taken:

buds fy, D;k mik; fd;s x,% Referrals (if any, with reason):

fdlh vkSj MkWDVj dks fn[kus dh lykg ¼dkj.k ds lkFk½% 82


Ophthalmic examination

vk¡[kksa dh tkap (This is done after a period of 6 months) ¼;g gj 6 eghus esa fd;k tk;sxk½

Date: ________________

Doctor’s Name: _______________________

frfFk% ________________

MkWDVj dk uke% _______________________

Chief complaint

eq[; f'kdk;r Ext ocular

Visual Acquity

,DlVjuy vkSdqyj

fot+qvy ,D;qVh

Distance vision nwj dh n`f"V

(Rt. Eye) ¼nk;ha vk¡[k½

(Lt. Eye) ¼ck;ha vk¡[k½

Near Vision ikl dh n`f"V

(Rt. Eye) ¼nk;ha vk¡[k½

(Lt. Eye) ¼ck;ha vk¡[k½

Fundus

QaM~l Doctors Observations:

MkWDVj dk voyksdu% Treatment Advice:

mipkj dh lykg% Action taken:

buds fy, D;k mik; fd;s x,% Referrals (if any, with reason):

fdlh vkSj MkWDVj dks fn[kus dh lykg ¼dkj.k ds lkFk½% 83


Dental checkup

nkarksa dh tkap (This will be done after a period of 6 months)

¼;g gj 6 eghus esa fd;k tk;sxk½ Date: _____________________

Doctor’s Name: ______________________

frfFk% _____________________

MkWDVj dk uke% ______________________

Chief complaint

eq[; f'kdk;r Intra oral examination

varj ekSf[kd tkap Plaque score

Iykd Ldksj

0

1 2

3

Related findings

lEcaf/kr fu"d"kZ Present miyC/k Cross bite ØkSl ckbV Oral bite vksjy ckbV Supernumerly/retained tooth jhVsauM VwFk

84

Not present miyC/k ugha

Details o.kZu


Congenitally missing tooth [kks;k gqvk nkar Ectopic eruption ,DVksfid bjI'ku Temporomandibular joint problem VsEikseSaMhcqyj tksbaV izkWCye

Other anomalies vU; folaxfr;ka

Doctors Observations:

MkWDVj dk voyksdu% Treatment Advice:

mipkj dh lykg% Action taken:

buds fy, D;k mik; fd;s x,% Referrals (if any, with reason):

fdlh vkSj MkWDVj dks fn[kus dh lykg ¼dkj.k ds lkFk½%

85


86

Date of birth/Age (as on…………):

Any other vU;

Hepatitis B gsfiVkbZVl ch

Typhoid VkbZQkbM

MMR ,e-,e-vkj

Tetanus VsVul

De-worming Mh&ofe±x Immunisation (Vaccine Name and Date) Vhdkdj.k ¼Vhds dk uke vkSj frfFk½

Weight for age

Height for age

BMI for age ch-,We-vkbZ

Height (in cm) ÅapkbZ ¼lsaVhehVj esa½ Weight (in Kg) ot+u ¼fdyksxzke esa½

Jan Feb tuojh Qjojh

Mar ekpZ

Apr vizSy

May ebZ

June twu

July tqykbZ

Aug vxLr

Sept Oct Nov lIrEcj vDVwcj uoEcj

Dec fnlEcj

iwjk uke vkSj miuke ¼vijdsl esa½% mez@tue frfFk ¼----------------------- rkjh[k ij½%

Full Name and Alias (Capital Letters):

ekfld LoLF; tkaplwph

Health Plan: Yearlong Health checklist

Annexure 1 (ii) – Annual Health Plan for the Child


87

Name ¼uke½ ………………….......

Signature of the health worker ¼gSYFkodZj ds gLrk{kj½ …………………

Any other specific health intervention planned for the child (based on the initial health assessment and physician’s observations):

Physician’s examination MkWDVj dh tkap Dental Check up nkarksa dh tkap Eye check-up vk¡[kksa dh tkap Referrals (Gynaecologist / skin specialist etc.) (Details of this information can be written in the table below) L=khjksx fo'ks"kK ls tkap


Information on referrals made: S.No.

88

Date

Presenting Problem

Advice


Annexure 1 (iii) - Monthly format on the Health Status of all Children Monthly Report on Health Care at Home The monthly report of the health worker should cover the following points: 1.

Total number of children in the home.

2.

Number of new children who have entered the home.

3.

Number of health assessments done of the new entrants.

4.

Number of new health plans drawn out for the new entrants.

5.

Visit by a physician to the home.

6.

Any visit by any of the other panel of doctors/specialists.

7.

Number of children referred (% for eye, % for dental and other cases).

8.

Number of children who needed hospitalisation (in % also) and the reason.

9.

Number and types of diagnostics and investigations needed.

10. Number who needed first-aid. 11. Any emergency cases and kind of intervention. 12. Any health camps organised (for what purpose) 13. Number of immunisations covered (Target for the month and % target fulfilled). 14. Number receiving TB/DOTS treatment. 15. Number who were given de-worming (what was the target for the month and % covered). 16. Iron Distribution (Target for the month and % target fulfilled). 17. Any health education sessions taken and the topics covered. 18. Number of malnourished children and interventions being taken (% of malnourished children). 19. Status of malnourished children from previous month (target and % covered). 20. Water tank cleaning. 21. Any other issue that needs to be reported.

89


90

Sl no

Medicine

Amoxicillin

Ciprofloxacin

Cotrimoxazole

Lincomycin

Metronidazole

1

2

3

4

5

Antibiotics

¼-¼

80 mg TMP + 400 mg SMX

2-2

1½ 1½

¼-¼ -¼ X

X

¼-¼ -¼

400 mg tablet

½-½ -½

½-½ -½

¼-¼ -¼ X

200 mg tablet

10 - 10 10

10 - 10

1-1

7.5 - 7.5 - 7.5

7.5 - 7.5

1–1

1-1

x

½-½

20 – 29

½-½ -½

1-1–1

15 - 15 - 15

X

1–1

1½ 1½

3–3

X

1½ - 1½ 2-2–2 - 1½

15 - 19

X

1-1-1

10 – 14

2.5 ml - 2.5 5-5–5 - 2.5

5–5

½-½

½-½

1

X

1-1–1

06 – 09

Weight in kilograms (Kg)

125 mg / 5 ml

40 mg TMP + 200mg SMX 2.5 ml - 2.5 syrup / 5 ml

¼-¼

½-½

100 mg dispersible tablet

250 mg tablet

X

½-½-½

03 – 05

500 mg capsule

125 mg dispersible tablet

How available

Ready reckoner for oral medications

Annexure 2(i): Drug formulary

1-1-1

X

X

X

2–2

2–2

X

1-1-1

X

30 - 44

1-1–1

X

X

X

2–2

2–2

X

1-1–1

X

45+


91

Cefixime

Azithromycin

Furazolidone

7

8

9

10

Chloroquine

Chloroquine

Antimalarials

Doxycycline

6

Syrup 50 mg / 5 ml

150 mg tablet

100 mg tablet

100 mg tablet

100 mg dispersible tablet

100 mg capsule

Day 3: 7.5 ml

Day 3: 5 ml

Day 3: 2.5 ml

Day 1: 15 ml Day 2: 15 ml

Day 1: 7.5 ml

Day 2:7.5 Day 2: 5 ml ml

Day 1: 5 ml

Day 3: ½ Day 3: 1

Day 3: ½

Day 2: 1

Use Tablet Formula

Day 3: 1

Day 2: 1

Day 1: 1½

¼-¼ -¼

¼-¼ -¼

Day 1: 1½

1-1

x

1

¾-¾

X

Day 2: 1

Day 1: 1

X

¾

½ -½

X

Day 2: ½

Day 1: ½

X

½

¼ -¼

X

Day 2: 3

Day 2: 1½

Use Tablet Formula

X

X

X

Day 3: 1 Day 3: 2

Day 1: 3

1- 1 - 1

Day 1:1½

½-½ -½

X

1–1

X

X

X

Day 3: 2

Day 2: 4

Day 1: 4

1-1–1

Use Doxycycline if patient is not pregnant

X

1¼ 1¼ 2½

1-1

½-½


92

INH

Rifampicin

Rimactazid Desped

Pyrazinamide

Ethambutol

13

14

15

16

17

X

¼

400 mg tablet

800 mg tablet

X

500 mg tablet

750 mg tablet

½

100 mg RIF, 50 mg INH

X

Use syrup

150 mg capsule

450 mg capsule

X

¼

½

¼

300 mg tablet

100 mg tablet

7.5 mg tablet

Primaquine 0.7 mg / kg / dose

12

Anti-Tuberculosis

(500 + 25) tablet

Sulfadoxine pyrimethamine

11

X

X

½

1

X

½

X

½

¾

½

X

¾

½

X

X

1

X

¾

1

x

1

x

1

2

½

x

x

1

2

1

X

1

X

X

X

2

X

1

X

X

2

X

1

X

X

4

2

1

X

2

X

X

1

X

1

X

5

3


93

Amlodipine

Methyldopa

19

20

Antiasthma

23

Ibuprofen

Griseofulvin

22

Pain

Fluconazole

21

Antifungal

Hydrochorothiazide

18

Anti Hypertensives

400 mg tablet X

X

X

125 mg tablet

200 mg tablet

X

X

X

X

150 mg tablet Weekly ones

250 mg tablet

5 mg tablet

25 mg tablet

X

¼-¼ -¼

½ -½

X

X

X

X

X

¼-¼ -¼

1–1

X

X

X

X

¼-¼ -¼

½-½ -½

1 ½ - 1½

x

x

x

x

½-½ -½

1-1–1

2–2

X

X

X

X

1- 1 - 1

X

3-3

1

2-2-2

1-1-1

½

1-1-1

X

4–4

1

1-1–1

1-1–1

½


94

Aminophylline

25

Dicyclomine

Iron

Codeine

Digoxin elixir 10 mcg / kg / day

26

28

30

31

Others

Salbutamol

24

0.5 ml

50 mcg/ml

X

¼-¼-¼ -¼

10 mg tablet

0.25 mg tablet

2.5 ml

6 mg iron per ml (Syrup)

X

60 mg iron (tab)

X

100 mg tablet

X

½-½

4 mg tablet

20 mg tablets

2.5 ml - 2.5 - 2.5

2 mg / 5 ml syrup

X

0.8 ml

½-½½- ½

4 ml

X

X

¼-¼ -¼

½-½

2.5 - 2.5 - 2.5

X

1.3 ml

1-1-1 -1

6 ml

½

¼-¼ -¼

½-½ -½

1–1

5-5-5

½

½

X

2-2-2 -2

1½ - 1½ - 1½ 1½ x

X

1-1

½-½ -½

1-1–1

1½ 1½

X

x

½

¼-¼ -¼

¾-¾ -¾

1-1

5-5-5

½

X

3-3-3 -3

X

1-1

1-1-1

1-1-1

2–2

X

1

X

3-3-3 –3

X

1-1-1 in severe anaemia

1-1–1

1-1–1

2–2

X


95

Phenytoin

Metoclopramide

Paracetamol

34

35

36

Furosemide

12 drops 12 – 12

X

100 mg tablet 10 mg tablet. Syrup 5 mg / 5 ml 500 mg tablet

½ ¼ -¼

10 mg tablet 40 mg tablet

Syrup 125 2.5 ml - 2.5 mg / 5 ml - 2.5 - 2.5

X

1 ml - 1 - 1

4 mg

2 mg / 5 ml syrup

½-½

½

5-5-5 –5

¼-¼¼-¼

20 drops - 20 – 20

½

X

2.5 - 2.5 - 2.5

½ -½

1

7.5 - 7.5 - 7.5 7.5

¼-¼¼-¼

¼-¼ -¼

¾

X

4-4-4

1-1

1.5

10 - 10 10 - 10

½-½½-½

¼-¼ -¼

1–1

2.5

X

½-½½ -½

½-½ -½

½-½ -½

½-½ -½ 1 1/2

X

x

1-1

3

X

1-1-1 -1

1-1-1

2

1-1-1 -1

X

1-1

4

X

1-1-1 –1

1-1–1

3

1-1-1 –1

X

Reference: 1. WHO. Pocket Book of Hospital Care for Children. 2005; 2. Singh M, Deorari AK. Drug Doses in Children, 7th Edn. 2007.

Developed by: Dr. Rakesh Lodha, Mr. Yogesh Kumar, AIIMS; Dr. Yogesh Jain, JSS

38

Prednisolone

CPM tablet

33

37

CPM Syrup 0.35 mg / kg / day

32


96

Vial of 10 lakh units to be mixed in 9.6 ml water for injection

Benzyl penicillin (penicillin G) IV 50,000 units / kg every 6 hours

Benzyl penicillin (penicil600 mg vial to be 0.4 - 0.4 - 0.75 - 0.75 lin G) IM mixed in 1.6 ml 0.4 - 0.4 0.75 - 0.75 500,000 units water for injection / kg every 6 hours

3

4

2-2-2 –2

15 - 19

2 ml

1.2 - 1.2 1.2 - 1.2

1.7 - 1.7 1.7 - 1.7

8.5 - 8.5 8.5 - 8.5

2 ml

3-3-3-3 5-5-5-5

10 - 14

3.75 - 3.75 6-6-6-6 3.75 - 3.75

X

2

X

IM, vial of 12 lakh units to be mixed in 4 ml water for injection

2-2-2-2

06 – 09

Benzathine penicillin 50,000 units / kg

1-1-1 –1

03 - 05

Ampicillin IV

Preparation

1

Drug

500 mg vial to be mixed in 2.1 ml sterile water for injection to make 500 mg / 2.5 ml

Antibiotics

S. no.

Intravenous medications ready reckoner Weight in Kilograms (Kg)

Annexure 2 (ii): Intravenous Medications

4 ml

7.5 - 7.5 - 7.5 - 7.5

30 - 44

4 ml

10 - 10 10 - 10

45+

2.5 - 2.5 2.5 - 2.5

3-33-3

4-44-4

12.5 - 12.5 15 - 15 - 20 - 20 - 20 - 12.5 15 - 15 - 20 12.5

4 ml

6-66-6

20 - 29


97

6

9

8

7

Ceftriaxone IM/IV

5

0.5 ml

Mix 500 mg vial 0.8 - 0.8 in 2 ml of sterile 0.8 - 0.8 water for injection

Gentamicin 7.5 80 mg /2 ml IM/ mg / kg IM IV vial / IV

Cefotaxime IM/IV

2–2

X

3 ml

250 mg vial to be mixed in 2 ml sterile water for injection

1 gm vial to be mixed in 9.6 ml water for injection

4-4-4 –4

600 mg vial to be mixed in 9.6 ml water for injection

Ceftriax1 gm vial to be one IM/IV mixed in 9.6 ml (For meningitis) water for injection

Benzyl penicillin (penicillin G) For meningitis 1 lakh units / kg every 6 hours IV

1.1 ml

1.5 - 1.5 1.5 - 1.5

4–4

X

5 ml

7.5 - 7.5 7.5 - 7.5

1.9 ml

2.5 - 2.5 2.5 - 2.5

6-6

10 ml

x

12 - 12 12 - 12

2.8 ml

3.5 - 3.5 3.5 - 3.5

9-9

14 ml

x

17 - 17 17 - 17

3.8 ml

5-55-5

12.5 - 12.5

20 ml

x

35 - 35 35 - 35

5 ml

x

20 - 20

20 ml

x

6 ml

x

20 - 20

30 ml

x

35 - 35 - 45 - 45 - 45 35 - 35 - 45


98

11

10

Loading dose 20 mg / kg, slow IV over 4 hours, give in a drip of 10 ml / kg 5% dextrose

0.3 ml in 50 ml 5% D

Quinine IM 2 ml ampoule to be diluted in 8 ml water for injection to make 60 mg / ml. Dose to be divided in two and given in both thighs deep IM

Maintenance

Loading

0.75 - 0.75 0.75

1.5 - 1.5 1.5

Quinine IV IV quinine 300 mg / ml, 2 ml Maintenance dose ampoule 10 mg / kg over 0.15 ml in 4 hours, given in 50 ml 5% a drip of 10 ml / D (3 kg 5% dextrose times) every 8 hours

Antimalarial

1.5 - 1.5 1.5

3/3/2003

0.3 ml in 80 ml 5%D (3 times)

0.6 ml in 80 ml 5%D

2.5 - 2.5 2.5

5/5/2005

0.5 ml in 120 ml 5% D (3 times)

1 ml in 120 ml 5%D

3-3-3

6/6/2006

0.6 ml in 180 ml 5% D (3 times)

1.2 ml in 180 ml 5%D

5-5-5

10/10/ 2010

1 ml in 250 ml 5% D (3 times)

2 ml in 250 ml 5%D

7-7-7

14 - 14 14

1.4 ml in 400 ml 5% D (3 times)

2.8 ml in 400 ml 5% D

8.25 - 8.25 - 8.25

16.5 - 16.5 - 16.5

1.6 ml in 500 ml 5% D (3 times)

3.3 ml in 500 ml 5% D


99

14

13

12

Artemether 80 mg / ml; Ampoule of 1 ml Given IM only

Artesunate IV 2.4 mg / kg. Mix 60 mg vial in 1 ml of Soda bicarb and then dilute with 5 ml sterile water for injection Artesunate IM Mix 60 mg vial in 1 ml Soda bicarb and then dilute with 2 ml sterile water for injection

0.1 ml

0.2 ml

Loading dose 3.2 mg / kg

Maintenance dose 1.6 mg / kg

0.3 ml

0.6 ml

Loading

Maintenance

0.6 ml

1.2 ml

Maintenance

Loading

0.2 ml

0.4 ml

0.5 ml

1 ml

1 ml

2 ml

0.3 ml

0.6 ml

0.75 ml

1.5 ml

1.5 ml

3 ml

0.4 ml

0.8 ml

1 ml

2 ml

2 ml

4 ml

0.6 ml

1.2 ml

1.5 ml

3 ml

3 ml

6 ml

0.75 ml

1.5 ml

2.3 ml

4.5 ml

4.5 ml

9 ml

1 ml

2 ml

3 ml

6 ml

6 ml

12 ml


100 0.5 ml

2.5 ml

0.8 ml

4 ml syrup 7.5 ml syrup

Syrup 2 mg / 5 ml Injection 10 mg / 2 ml ampoule

Diazepam (rectal) 0.4 mg / kg / dose

18

X

10 mg / ml; 2 ml ampoule

Diazepam I.V.

17

0.4 ml

1.5 ml

16

Mix 1 ml of 1:1000 solution with 9 ml water for injection to make 1:10,000 solution

50 mg / ml 2 ml / ampoule

Phenytoin 15 mg / kg, slow IV, over 15 minutes

For seizures

15

Adrenaline 0.01 ml / kg of 1:10,000 solution

For anaphylactic shock

10 ml syrup

0.8 ml

4.5 ml

1.3 ml

15 ml syrup

1.1ml

6 ml

1.7 ml

20 ml syrup

1.5 ml

9 ml

2.7 ml

2 ml

15 ml

5 ml

2 ml injec2 ml injection tion

2 ml

12 ml

4 ml


101

10 mg / ml IV; 2 ml ampoule

5 mg / ml 2 ml ampoule

Metoclopramide 0.15 mg / kg / dose

21

Maintenance dose IV 5 mg / kg every 6 hours

Loading dose 5-6 mg IV / kg (maximum 300 mg), very slow IV, over 30 minutes

20

Aminophylline 250 mg / 10 ml vial

Furosemide (frusemide) 1-2 mg / kg every 12 hours

Others

19

For Asthma

X

0.4 - 0.4

1-1-1 -1

1 ml

0.1 - 0.1 0.1 - 0.1

0.8 - 0.8

1.5 - 1.5 1.5 - 1.5

1.5 ml

0.4 - 0.4 0.4 - 0.4

1.2 - 1.2

2.5 - 2.5 2.5 - 2.5

2.5 ml

0.5 - 0.5 0.5 - 0.5

1.7 - 1.7

3.5 - 3.5 3.5 - 3.5

3.5 ml

0.8 - 0.8 0.8 - 0.8

2.5 - 2.5

5-5-5 -5

5 ml

1-1-1 -1

3-3

8-8-8 -8

8 ml

1.5 - 1.5 1.5 - 1.5

4-4

10 - 10 - 10 â&#x20AC;&#x201C; 10

10 ml


102

25 mg / ml 3 ml ampoule

Diclofenac 2 mg / kg / dose

Intravenous Rehydration 5% Dextrose or NS or RL In severe dehydration / shock

Snake Antivenin (ASV)

22

23

24

25

1000 ml

750 ml

1.5 ml

0.4 ml

1500 ml

1000 ml

2 ml

0.6 ml

2500 ml

1500 ml

2.5 ml

0.8 ml

2500 ml

2000 ml

3 ml

1 ml

Reference: 1. WHO. Pocket Book of Hospital Care for Children. 2005; 2. Singh M, Deorari AK. Drug Doses in Children, 7th Edn. 2007.

Developed by : Dr. Rakesh Lodha, Mr. Yogesh Kumar, AIIMS; Dr. Yogesh Jain, JSS

If there are signs of envenomation, give 10 vials of antivenin mixed with 400 ml of IV fluid (DNS, RL, 5D) over one hour. Repeat after six hours if needed. Test dose NOT required. S

800 ml

500 ml

1 ml

0.4 ml

Lyophilised powder to make up to 10 ml with water for injection, OR 10 ml / vial solution

550 ml

250 ml

0.5 ml

0.2 ml

350 ml

150 ml

X

0.2 ml

2nd to 6th hours (part of this can be given as ORS)

First hour

0.5 mg / ml ampoule

Atropine 0.01 mg / kg / dose


Annexure 2 (iii): Locost drug price list PRICE LIST : JAN. - MAR. 2011 ABBREVIATIONS USED : (S.C.) : Sugar Coated (F.C.) : Film Coated (E.C.) : Enteric Coated (R) : Items not manufactured by LOCOST No. NAME 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Albendazole Albendazole (Strip Pack) Alprazolam (Strip Pack) (R) Alprazolam (Strip Pack) (R) Aluminium Hydroxide + Magnesium Trisilicate Aluminium Hydroxide + Magnesium Trisilicate (Strip Pack) Aminophylline (Strip Pack) Amlodipine (Strip Pack) Amoxycillin Amoxycillin (Strip Pack) Amoxycillin Amoxycillin (Strip Pack) Amoxycillin (Strip Pack) (R) Disp. Aspirin (Strip Pack) Aspirin Atenolol (Strip Pack) Atorvastatin (Strip Pack) (R) Atorvastatin (Strip Pack) (R) Azithromycin (Strip Pack) (R) Azithromycin (Strip Pack) (R) Bisacodyl (Strip Pack) (R) Calcium Lactate Calcium Lactate (Strip Pack) Carbamazepine (Strip Pack) Cephalexin (Strip Pack) Cephalexin (Strip Pack) Cetrizine (Strip Pack) Chloroquine Phosphate (F.C.) Chloroquine Phos. (F.C.) (Strip Pack) Chloroquine Phosphate Syrup (R) Chlorphenirmine Maleate Ciprofloxacin (F.C.) (Strip Pack) (R) Ciprofloxacin (F.C.) (Strip Pack)

STRENGTH (in mg) 400 400 0.25 0.5 120 +250 120 +250 100 5 250 250 500 500 125 75 300 50 10 20 250 500 5 300 300 200 250 500 10 250 250 80/5ml 4 250 500

MINIMUM PACK SIZE

LIFE IN YEARS

PRICE (Rs) /1000 Units

5x100 25x10 60x10 60x10 1000

3 3 2 2 3

1050.00 1100.00 150.00 175.00 130.00

25x10

3

180.00

25x10 25x10 100 25x10 100 25x10 25x10 25x14 10x100 25x14 20x10 20x10 10x6 10x3 20x10 1000 25x10 25x10 25x10 25x10 25x10 10x100 25x10 60ml 1000 20x10 25x10

3 2 2 2 2 2 2 2 2 3 2 2 2 2 2 3 3 2 2 2 2 3 3 3 3 3 3

225.00 300.00 800.00 850.00 1500.00 1550.00 600.00 135.00 135.00 250.00 1500.00 2600.00 5000.00 9000.00 325.00 80.00 130.00 725.00 1550.00 2750.00 125.00 400.00 450.00 9.25/Bott. 50.00 800.00 1450.00

ORDER

103


No. NAME 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74

104

Codeine Phosphate (R) Cotrimoxazole (S.S.) Cotrimoxazole (S.S.) (Strip Pack) Cotrimoxazole (D.S.) Cotrimoxazole (D.S.) (Strip Pack) Cotrimoxazole Syrup (R) Cotrimoxazole Syrup (R) Diazepam (Strip Pack) Diclofenac Sodium (E.C.) (Strip Pack) Dicyclomine (R) Diethyl Carbamazine Citrate Doxycycline Doxycycline (Strip Pack) Enalapril Maleate (Strip Pack) Ethambutol (Strip Pack) Ethambutol (Strip Pack) Famotidine (F.C.) (Strip Pack) (R) Famotidine (F.C.) (Strip Pack) (R) Ferrous Sulphate+Folic Acid (S.C.) (R) Ferrous Sulphate+ Folic Acid (S.C.) (R) (Strip Pack) Ferrous Sulphate+ Folic Acid (S.C.) (R) Fluconazole (Strip Pack) Fluoxetine (R) (Strip Pack) Folic Acid Folic Acid (Strip Pack) Furazolidone (Strip Pack) Glibenclamide (Strip Pack) Glipizide Griseofulvin (Strip Pack) Hydrochlorothiazide (Strip Pack) Ibuprofen (F.C.) (R) Ibuprofen (F.C.) Ibuprofen (F.C.) (Strip Pack) Imipramine (R) Indomethacin (Strip Pack) Isoniazid (INH) (R) Isoniazid (INH) Isoniazid (INH) (Strip Pack) Mebendazole (Strip Pack) Metformin Hydrochloride (Strip Pack) Metoclopramide (Strip Pack)

STRENGTH (in mg)

MINIMUM PACK SIZE

LIFE IN YEARS

PRICE (Rs) /1000 Units

10 80+400 80+400 160+800 160+800 40+200/5ml 40+200/5ml 5 50 20 100 100 100 5 400 800 20 40 200+1 200+1

10x100 10x100 25x10 5x100 25x10 50ml 450ml 25x10 25x10 1000 1000 100 25x10 25x10 25x10 25x10 50x14 50x14 1000 10x5x10

2 3 3 3 3 2 2 3 3 2 2 2 2 2 3 3 2 2 2 2

675.00 480.00 500.00 850.00 900.00 10.50Bott. 60.00/Bott. 125.00 200.00 120.00 250.00 650.00 700.00 350.00 1275.00 2500.00 200.00 300.00 50.00 110.00

60+0.1

1000

2

35.00

150 20 5 5 100 5 5 125 25 200 400 400 25 25 100 300 300 100 500 10

5x10 20x10 1000 25x10 25x10 25x10 25x10 25x10 25x10 10x100 5x100 25x10 4x30 25x10 1000 1000 25x10 25x10 25x10 25x10

3 2 2 2 3 3 2 2 2 3 3 3 2 2 3 3 3 2 2 2

2500.00 725.00 65.00 115.00 200.00 275.00 300.00 875.00 250.00 425.00 475.00 500.00 525.00 160.00 325.00 225.00 375.00 225.00 350.00 175.00

ORDER


No.

NAME

75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103

Metronidazole (F.C.) Metronidazole (F.C.) Metronidazole (F.C.) Metronidazole (F.C.) (Strip Pack) Metronidazole Benzoate Syrup (R) Nifedipine (Strip Pack) (R) Norfloxacin (F.C.) (Strip Pack) (R) Ofloxacin (F.C.) (Strip Pack) (R) Oral Rehydration Salt Paracetamol Paracetamol (Strip Pack) Paracetamol Syrup (R) Paracetamol Syrup (R) Phenobarbitone (Strip Pack) (R) Phenobarbitone (Strip Pack) (R) Pyrazinamide (Strip Pack) Pyrazinamide (Strip Pack) Quinine Sulphate (S.C.) (R) Ranitidine (F.C.) (Strip Pack) Rifampicin Rifampicin (Strip Pack) Rifampicin Rifampicin (Strip Pack) Risperidone (Strip Pack) (R) Risperidone (Strip Pack) (R) Salbutamol Salbutamol (Strip Pack) Sodium Valproate (Strip Pack) (R) Vitamin A (R)

104 105 106 107 108 109 110 111 112 113 114 115

Amikacin Injection (R) Amikacin Injection (R) Beclamethasone+Neomycin Oint. (R) Ceftriaxone (R) Ceftriaxone (R) Ceftriaxone (R) Ciprofloxacin Eye Drops (R) Clotrimazole Pessaries (R) Gamma Benzene Lotion (R) Gentamicin Eye / Ear Drops (R) Gentian Violet Solution (R) Miconazole Nitrate Oint. (R)

STRENGTH (in mg) 200 200 400 400 200/5ml 10 400 200 21.0gm 500 500 125/5ml 125/5ml 30 60 500 750 300 150 150 150 450 450 1 2 4 4 200 2 lac I.U.

MINIMUM PACK SIZE 10x100 25x10 10x100 25x10 60ml 20x10 25x10 20x10 1 Litre 1000 25x10 60ml 4.5 Ltr. 4x30 4x30 25x10 25x10 25x10 25x10 100 25x10 100 25x10 5x40 5x40 2x500 25x10 10x10 100

LIFE IN YEARS 3 3 3 3 2 3 3 2 2 3 3 2 2 2 2 3 3 3 2 2 2 2 2 2 2 3 3 2 2

PRICE (Rs) /1000 Units

ORDER

275.00 300.00 475.00 525.00 11.00/Bott. 265.00 975.00 900.00 3.75 210.00 260.00 10.00/Bott. 475.00/Can 475.00 600.00 900.00 1300.00 2850.00 400.00 1200.00 1250.00 2900.00 2950.00 500.00 850.00 100.00 130.00 1275.00 1300.00

INJECTIONS, LOTIONS, CREAMS, OINTMENTS, EYE DROPS AND PESSARIES 100mg/2ml 500mg/2ml 0.12%+5%l 250 500 1000 0.30% 1% 0.3% 1% 0.2%

Vial Vial 15gm Tube Vial Vial Vial 10ml Vial 1x6 4.5 Ltr. 10ml Vial 400ml 15gm Tube

2 2 2 2 2 2 2 2 3 2 2 3

5.50/Vial 9.00/Vial 10.50/Tu. 11.00 16.00 20.00 7.50/Vial 10.00/6 Tab 400.00/Can 7.00/Vial 30.00 7.00

105


No.

NAME

116 117 118 119

Nitrofurazone Cream (R) Nitrofurazone Cream (R) Silver Sulphadiazone Oint (R) Whitfield's Oint (Benzoic Acid 6% + Salicylic Acid 3%) (R) Whitfield's Oint (Benzoic Acid 6% + Salicylic Acid 3%) (R)

120

STRENGTH (in mg) 0.2% 0.2% 1.0%

MINIMUM PACK SIZE

LIFE IN YEARS

PRICE (Rs) /1000 Units

15gm Tube 400gm Jar 20gm Tube 25gm Tube

2 2 2 3

5.25/Tu 25.00/Jar 12.00/Tu. 9.50/Tu

400gm Jar

3

80.00/Jar

ORDER

NEW PRODUCTS INTRODUCED BY LOCOST 121 117

Calcium Carbonate with Vitamin D3

250+ 125 I.U.

25x10

2

450.00

Locost is a non-governmental organisation making quality low-priced generics. The organisation can be contacted at: 1st Floor, Premanand Sahitya Sabha, Opp. Lakadi Pool, Dandia Bazar, VADODARA - 390 001. Tel. No.: (91-265) 2413319 E-mail: locost@satyam.net.in Website: www.locostindia.com

106


107

Annexure 3: z score Charts for Growth Monitoring


108


109


110


111


112


Bibliography Commissioners of the Supreme Court (2008), A Special Report on the Most Vulnerable Social Groups and their Access to Food, Eighth Report of the Commissioners of Supreme Court. Committee on Community Health Services (2005), Providing Care for Immigrant, Homeless and Migrant Children, in American Academy of Pediatrics, Vol. 115, No. 4, pp. 1095-1100. Department of Health (2000), Assessing Children in need and their families: A Practice Guidance, London: The Stationery Office. Department of Health (2002), Promoting the health of looked after children, London: Department of Health Publications. Deshpande, M., Rama. V. Baru and M. Nundy (2010), Understanding Childrenâ&#x20AC;&#x2122;s Health Needs and Programme Responsiveness, Working Paper Series 3, Vol. 1, University School Resource Network, New Delhi. Elsayed, D.E.M. (2007), Public Health and Ethics: An Overview in the Sudanese Journal of Public Health, Volume 2 (3), pp. 146-151. F. Philip Rice (1996), Child and Adolescent Development, Prentice Hall. Government of Chhattisgarh (2010), Essential Drug List 2010-2011 available at http:// www.shsrc.org/pdf/edl2010.pdf. Government of Chhattisgarh (2006), Jadi Buti le kar ilaaj: Mitanin ki Gharelu Ilaaj Pustika, State Health Services. Government of Chhattisgarh and NRHM (2009), Nanheman ka Paalan poshan aur paramarsh, Government of Chhattisgarh and NRHM. Government of Chhattisgarh, Mitanin module - Karya pustika 3 - Hamare bachhe unki sehat, Government of Chhattisgarh and NRHM. Government of India (2006), Reading Material for ASHA - Book 1 (Chapter 4 on Staying Healthy; Chapter 5 on Personal Hygiene; Chapter 6 Water Safety at Home; Chapter 7 Disposal of Waste water; Chapter 8 Our Health depends on the Food we eat; Chapter 9 Body Mapping and Overview of Organs; Chapter 15 Illness and Healing; Chapter 16 Using Remedies; Chapter 17 Home Remedies; Chapter 18 and 19 on Contraception; Chapter 22 on HIV/AIDS; Chapter 25 Immunisation;

113


Chapter 26 Diarrhoea; Chapter 27 Aches and Pains; Chapter 28 Understanding TB; Chapter 29 Snake Bites), National Rural Health Mission, Ministry of Health and Family Welfare. Government of India (2006), Reading Material for ASHA - Book 2 on Maternal and Child Health (Chapter 9 on Diarrhoea, Chapter 10 on Acute Respiratory Infections, Chapter 12 on Fever), National Rural Health Mission, Ministry of Health and Family Welfare. Government of India (2006), Reading Material for ASHA - Book 3 on Family Planning, RTIs/ STIs and HIV/AIDS, and ARSH, National Rural Health Mission, Ministry of Health and Family Welfare. Government of India (2010), Reading Material for ASHA - Book 4 on National Health Programmes, AYUSH and Management of Minor Ailments, National Rural Health Mission, Ministry of Health and Family Welfare. Government of India (2010), Reading Material for ASHA - Book 7 on Skills that Save Lives. Part A and Part D, National Rural Health Mission, Ministry of Health and Family Welfare. Khalakdina, M. (1980), Early Child Care in India, Gordon and Breach Science Pub. Locost (2010), Low Cost Standard Therapeutics Price List (Jan-March 2011) available at http://www.locostindia.com/pdf/pdf3.pdf (accessed on 30th May 2011). Mander, H. (2008), Living Rough: Surviving City Streets, Centre for Equity Studies. Matri Chhaya (1995), Suggestions for Crèche Workers: Part 2, Mobile Crèches, New Delhi. National Institute of Nutrition (2004 reprinted), Menus for Low-Cost Balanced Diets and School Lunch programme (Suitable for North and South India), Hyderabad. National Institute of Nutrition (2009 reprinted), Dietary Guidelines for Indians, Hyderabad. National Institute of Nutrition (2009 reprinted), Nutritive Value of Indian Foods, Hyderabad. NCERT (2006), Position Paper: National Focus Group on Health and Physical Education, NCERT Publication Department, New Delhi. Niemann, S., N. Jacob and H. Broner (2004), Helping Children who are Blind: Early Assistance Series for Children with Disabilities, Hesperian Foundation. Niemann, S., D. Greenstein and D. David (2004), Helping Children who are Deaf: Early Assistance Series for Children with Disabilities, Hesperian Foundation, Berkeley, California. 114


Park, K. and Park (2009), Parkâ&#x20AC;&#x2122;s Textbook of Preventive and Social Medicine, Ms. Banarsidas Bhanot Publishers, Jabalpur, MP, Twentieth edition. Patil, R. Participatory and Problem Solving Training Module on Communicable Diseases, Community Health Cell, Bangalore. PHRN (2008), Immunisation - Lesson 3 in PHRN (ed.) Accelerating Child Survival .Book 3, Public Health Resource Network. PHRN (2008), Issues in Child Health - Lesson 1 and 2 in PHRN (ed.) Accelerating Child Survival. Book 3, Public Health Resource Network. PHRN (2008), Social determinants and Health as a Right - Lesson 1 in PHRN (ed.) Introduction to Public Health Systems - Book 1, Public Health Resource Network. Prasad, V., S. Haripriya & S. Jacob (2010), Food Security of the Homeless in Delhi: A Study of the Nutritional Status and Dietary Intakes of Adult Homeless Persons in New Delhi, PHRN-CES, New Delhi. Rehabilitation Council of India (2007), Status of Disability in India. Rehabilitation Council of India, Training Manual on Disability Management and Mainstreaming of Persons with Disability for University and Management Institutions. Save the Children (2011), Surviving the Streets: A Census of Street Children in Delhi by the Institute of for Human Development and Save the Children, New Delhi. Sharma, S. GR Sethi, U Gupta (eds.) (2009), Standard treatment guidelines, Delhi Society for Promotion of Rational Use of Drugs (DSPRUD) and BI Publications. Singh, M. and A.K. Deorari (2001 reprinted), Drug dosages in children, Sagar Publishers, New Delhi. SNEHA (2008), Making Health Care Accessible to Street Children: The Hospital on Wheels Project (2000- 2006), Sneha: Mumbai. St. John.s Ambulance, Training Resources on First-Aid First-aid module available at http:// www.sja.org.uk/sja/first-aid-advice.aspx (accessed on 6th May 2011). WHO (2008), Training Course on Child Growth Assessment: WHO Child Growth Stan dards, available at http://www.who.int/childgrowth/training/en/ and http:// www.who.int/childgrowth/standards/en/ (accessed on 15th May 2011). WHO (2011), WHO Model List of Essential Medicines for Children and WHO Model List of Essential Medicines for Adults, World Health Organisation, essentialmedicines/ en/.

115


Abbreviation AIDS

Acquired immunodeficiency syndrome

ASHA

Accredited Social Health Activists

AYUSH

Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy

BCG

Bacillus Calmette-GuĂŠrin

BMI

Body Mass Index

CES

Centre for Equity Studies

CNS

Central Nervous System

CWC

Child Welfare Committee

DOTS

Direct Observed Therapy Short Course

ENT

Ears Nose Throat

HIV

Human immunodeficiency virus infection

IMNCI

Integrated management of neonatal and childhood illnesses

MMR

Measles, Mumps and Rubella

NA

Not Applicable

ORS

Oral Rehydration Solution

RTIs

Reproductive tract infections

STIs

Sexually Transmitted Infections

TB

Tuberculosis

UIN

Unique Identification Number

UN

United Nations

UK

United Kingdom

WHO

World Health Organization

116


la?k"kZ dh jkgksa esa la?k"kZ dh jkgksa esa] dksbZ rks gekjk gks---gj jkr dh ckgksa esa] lqcg dk ut+kjk gks

In this life full of strife In this life, full of strife, We long for a friend and guide... In the darkness of night We long for a dawn, warm and bright

la?k"kZ dh jkgksa esa] dksbZ rks gekjk gks---geus rks t+ekus dh] jaft'k dks gh ih Mkyk pqHkrs gq, gj iy dks] gl [ksy ds th Mkyk

In this life full of strife, We long for a friend and guide… We swallow hatred and the vile Stinging moments, with a smile

D;ksa iwN jgs gks rqe] D;k geus xok;k gS thou dh rks cl NksM+ks] gj [okc ijk;k gS

Why do you ask, what have we lost, Not just life, even our dreams went past...

la?k"kZ dh jkgksa esa] dksbZ rks gekjk gks----

In this life, full of strife We long for a friend and guide…

oks iy Hkh Fkk viuk] ;s iy Hkh gekjk gS la?k"kZ dh jkgksa esa] vc dksbZ gekjk gS---oks jkrsa feV gh xbZ] ,d lqcg vkbZ u;h py jgs veu dh jkgksa ij] gj [okc gekjk gS ,d vk'kk veu dh] gS vc bl fny esa dksbZ jkg u vc jksds] dqN dj ds fn[kkuk gS c<+k,axs ge dne dks] feVk;saxs gj xae dks pysaxs mu jkgksa ij] tgk¡ ls fn[krk fdukjk gS la?k"kZ dh jkgksa esa] gj dksbZ gekjk gS----

In this life, full of strife, We have someone as a guide and friend…

List of Team Members who Authored the Manuals Ambika Kapoor Anant Asthana Deepika Nair Dr. Madhurima Nundy Dr. Vandana Prasad Harsh Mander Harshdeep Singh Preeti Mathew Rachel Firestone Saheli Bhattacharya

That past was ours, this present is ours In this life, full of strife, Now we have someone as a guide and friend…

Satya Pillai

Those nights have passed, there dawns a new sun Walking on the paths of peace, every dream is ours

Sharmila Sinha

There is a ray of hope in this heart There is no stopping us; we have to achieve something now We will take a step forward, remove all the pain We will walk on paths in life, from where the shore is near In this life, full of strife, We have everyone as a guide and friend…

Written by one of the child from Sneh Ghars in Delhi

Shaheen Adreshir

Shashi Mendiratta Subroto Baul Sunil Snehi Sveta Dave Chakravarty


Open Hearts, Open Gatesâ&#x20AC;Ś.

Printed by: Print World # 9810185402

Comprehensive Care for Street Children: Handbook for Planners and Practitioners Physical Health Care

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Centre for Equity Studies

Indradhanush Academy Centre For Equity Studies

Indradhanush Academy

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