Prof. Pratibha Singhi Professor, Chief Pediatric Neurology and
Neurodevelopment, Department of Pediatrics, Postgraduate Institute
of Medical Education and Research, Chandigarh- INDIA AT RISK
CHILDREN
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Plan of Talk What is At Risk. Why is it so important in first 3
yrs of life Why are under threes more vulnerable What are the risk
factors. What is the current status. How to reach the under 3s.
What needs to be done.
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At risk is a concept that reflects a chance or a probability of
adverse outcome, the outcome is determined by a balance of adverse
and protective factors At risk is a concept that reflects a chance
or a probability of adverse outcome, the outcome is determined by a
balance of adverse and protective factors AT RISK Definition How do
you define ? No consistent definition WHO IS AT RISK? All children
are at risk in some way or another Some children face much higher
risks WHAT ARE CHILDREN AT RISK OF? Poor life outcomes - death,
inadequate development, school failure, economic dependency,
etc
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Why is Under 3 so important There is a high correlation between
the density of the neural connections and ones specific knowledge,
abilities or skills Critical periods Time window during which a
specific function develops normally provided conditions are
favorable Neuroplasticity - Synaptogenesis and Synaptic Pruning Age
of two, childs brain contains twice as many synapses and consumes
twice as much energy as the adult brain. Developmental and
environmental changes increase or decrease the strength or efficacy
of synapses as well as lead to the addition or pruning of synapses.
It is easier to expand a childs future proficiencies by using the
existing fertile neural networks
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Brain Development in Infants And Early Childhood Learning with
all five senses During the first 3 years of life, children
experience the world in a more complete way than children of any
other age. The brain takes in the external world through its system
of sight, hearing, smell, touch and taste. Infant - social,
emotional, cognitive, physical and language development are
stimulated during multisensory experiences. Infants and toddlers
need the opportunity to participate in a world filled with
stimulating sights, sounds and people. Early abuse and emotional
deprivation are extremely damaging
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0 1 481216 AGE Human Brain Development Synapse Formation
Sensory Pathways ( vision, hearing) Language Higher Cognitive
Function 3 6 9 -3 -6 Months Years C. Nelson, in From Neurons to
Neighborhoods, 2000 Conception
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Cortical organization, especially for the sensory systems, is
often described in terms of maps. Cortical Maps Brain Development
in Early Life Sets Trajectories for Development Throughout
Life
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Foundations of brain architecture Genetic factors Biological
factors Psychosocial factors Brain architecture The foundations of
brain architecture are laid down early in life through dynamic
interactions of genetic, biological, and psychosocial influences,
and child behaviour
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Attachment Attachment - deep emotional bond with a specific
person that lasts over time and spaces Stays with us for our
lifetime and guides our behavior Secure attachments greater
independence and socio- emotional competence and a secure base
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Kangaroo mother care
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Risk factors PovertyMental illness Young ageStress Poor
pre-natal care and nutritionLow self-esteem Domestic violencePoor
parenting skills Poor physical healthUnemployment Low educational
statusHomelessness Childhood experience of abuseSingle parent High
family conflict Poor family attachment/bonding Parental /
Family
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Child risk factors PovertyAdverse prenatal period (infections,
drugs, hypertension) Poor nutritionStress and depression
Pre-mature/low-birth weightDomestic violence Unwanted
pregnancyMaternal smoking or substance abuse Girl childDisability
Poverty Chaotic or unsafe home environment Isolation Household
composition Community rates of poverty, crime, unemployment,
Environmental risk factors
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At risk children Low birth weight Malnutrition Anemia Vit A
deficiency Orphans, street children Orphans, street children Sexual
exploitation Disabilities, Other chronic medical conditions-
epilepsy Disabilities, Other chronic medical conditions- epilepsy
Disasters - floods, Famines, Earthquakes, Nuclear explosion
Disasters - floods, Famines, Earthquakes, Nuclear explosion Drug
trafficking Unwanted, girl child Iodine, Micronutrient, deficiency
Commercial exploitation Poverty
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Data from Guatemala show a linear decrease in adolescents
school achievement and cognition with an increase in risk factors
encountered by age 3 years. Child Dev 1996; 67: 31426 Infant Behav
Dev 1992; 15: 27996
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Current Status Global Millions of children, particularly in
Africa and Asia, lack access to quality health- care services,
micronutrient supplementation, education, improved water sources
and sanitation facilities, and adequate shelter. In excess of 140
million under fives are underweight for their age, 100 million
children of primary school age are not enrolled in primary school.
500 million to 1.5 billion children experience violence annually.
Around 150 million children aged 514 are engaged in child labour
India Every fifth child in the world and every third malnourished
child in the world lives in India, Every second Indian child is
underweight, three out of four children in India are anaemic. Every
second new born has reduced learning capacity due to iodine
deficiency
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Causes of mortality under 5yrs of age Globally > a third of
deaths are due to underlying malnutrition
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Childhood Malnutrition Worst-affected region is not Africa but
South Asia!!. Underweight children - Africa 30%, South Asia - over
50%. Bangladesh and India,- proportion of malnourished children
significantly higher than in even the poorest countries of the
sub-Sahara. Not just because of sheer size of its populations but
even the proportion affected is far higher Half of the world's
malnourished children are to be found in just three countries -
Bangladesh, India, and Pakistan.!!! Malnutrition Among Children
Under Five Years % Stunted 48 Wasted 20 Underweight 43 Malnutrition
Among Children Under Five Years % Stunted 48 Wasted 20 Underweight
43
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Childhood Malnutrition long term effects Beyond the age of 2-3
years, the effects of chronic malnutrition are irreversible -
Cognitive impairments Greater risk of infection Less physical
capacity for work Less Educational attainment- stunted children in
the first two years of life have lower cognitive test scores,
delayed enrolment, higher absenteeism and more class repetition
compared with non stunted children. To break the intergenerational
transmission of poverty and malnutrition, children at risk must be
reached during their first two years of life (N Engl J Med 1991;
325: 2317.) (J Nutr. 125: 2221S-2232S, 1995) Int. J. Environ. Res.
Public Health 2011 8, 590-612; oi:10.3390/ijerph8020590
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Malnutrition and infections a Vicious circle !! Poor immune
response Unusual organisms Severe infections Poor outcome Recurrent
infectionsfurther malnutrition Malnutrition - impact on behaviour
Children malnourished at age 3 were more likely than other children
to be aggressive or hyperactive at age 8, To exhibit externalizing
behaviors at age 11, Exhibit conduct disorder and Hyperactivity at
age 17. Crime times Volume 11, Number 1, 2005
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Child malnutrition is a gender issue in India and is
Intergenerational Prevention of chronic fetal malnutrition is a
high priority for developing countries !!
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Anemia in Children and Anemia in Pregnancy 70% of children age
6-59 months are anaemic. Severe 3%, Moderate 40%, Mild 26% Iron
deficiency anemia in early life - altered behavioral and neural
development. Irreversible effect that may be related to changes in
chemistry of neurotransmitters, organization and morphology of
neuronal networks, and neurobiology of myelination. India 58.7% of
pregnant women, 63.2% lactating mothers are anaemic. Iron
deficiency in pregnancy affects cells which are involved in
building the embryonic brain during first trimester - most
sensitive to low iron levels. Critical period starts in the weeks
prior to conception and extends through the first trimester till
the onset of the second trimester. Iron deficiency which starts in
the third trimester does not seem to harm the developing
brain.
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Iodine deficiency Iodine deficiency during pregnancy can cause
abortion, CP and MR- single largest preventable cause of mental
retardation in the world Fifty per cent of children born every year
in India are unprotected against Iodine Deficiency Disorders such
as brain damage, deaf mutism, dwarfism and severely depleted levels
of productivity. The degree of impairment in function is related to
the severity of iodine deficiency. Even marginal degrees of iodine
deficiency have a measurable impact on human development Only 71%
of households currently consume adequately iodized salt.
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Vitamin A Deficiency 62% of pre-school children are deficient
in vitamin A - Leading to an annual 330,000 child deaths. Night
blindness - first sign of vitamin A deficiency. Xerophthalmia and
complete blindness can also occur. Approx 250,000 to 500,000
malnourished children in the developing world go blind each year
from a deficiency of vitamin A. - Approx half of them die within a
year of becoming blind. Vitamin A deficiency reduces immunity The
Unites Nations Special Session on Children in 2002 set the
elimination of vitamin A deficiency by 2010. - but have we achieved
it?? Prevalence of vitamin A deficiency. Source: WHO
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Vitamin deficiency Vitamin C ScurvyVitamin D Rickets
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NUTRITIONAL DEFICIENCIES AND COGNITION Nutritional
deficiencies- General - protein energy malnutrition (PEM) Stunting
(chronic PEM) Consistent predictor Vs wasting Low birth weight SGA
babies (12 long studies) Lack of breast feeding (14 studies)
Specific - deficiency of iodine, trace metals, essential fatty
acids Prolonged anemia ? Confounding environmental variables
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Developmental delay and Childhood Disability Factors adversely
affecting development Perinatal: traumatic labour, hypoxic ischemic
encephalopathy, intraventricular hemorrhage, Postnatal: neonatal
seizures, infections, symptomatic hypoglycemia, hyperbilirubinemia
Miscellaneous: Socio-environmental influences- - Low socioeconomic
status - - A key determinant of development during the first 5
years - Child abuse & neglect Disease states-e.g. severe
epilepsy, certain neurological infections & disorders, chronic
debilitating illness
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Childhood Disability Associated problems Speech and Language
Hearing and Vision Epilepsy, Behavior Problems Feeding and
Nutrition Co-morbidities
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Non Accidental Injury Death due to abuses most common in
infancy - of severe head injuries in infancy 95% are due to abuse
Pattern of NAH injuries in infancy Skull rib and long bone
fractures, bruising anywhere retinal hemorrhages subdural hematomas
Poverty, Drugs and alcohol, unwanted child
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Long-Term Consequences of Child Abuse and Neglect Factors
Affecting - The child's age and developmental status when the abuse
or neglect occurred The type of abuse (physical abuse, neglect,
sexual abuse, etc.) Frequency, duration, and severity of abuse
Relationship between the victim and his or her abuser (Chalk,
Gibbons, & Scarupa, 2002 ) Physical, psychological, behavioral,
and societal consequences
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Non-organic failure to thrive Typically develops in the early
months of postnatal life; may develop later Long term deficits in
physical growth, cognitive functioning and emotional and social
development, inadequate nutrition Development delays,behavioural
and emotional signs are frequent Risk factors - Poor Maternal
attachment - Unwanted pregnancy or the result of rape or abuse -
Maternal postnatal depression, drug or alcohol abuse, - Domestic
violence, Less frequent verbal and physical contact less positive
reinforcement and warmth Lack of parenting skills, emotional
hostility, parental indifference, withdrawal and rejection common
features of NOFIT emotional abuse and neglect - links with physical
and sexual abuse
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Disasters Sikkim earthquake More than 200,000 hit by floods in
India, Nepal Kathmandu July 13, 2011 Millions of Pakistan children
at risk of flood diseases Asia Pacific region vulnerability Over
50% of the total world disasters Over 70% of lives lost to
disasters occur in this region 75% of global flood mortality risk
is in Bangladesh, China and India GDP losses of between 2-20%
Consequences -Child Poverty, malnutrition, diseases, separation
from parents, loss of school etc etc Consequences -Child Poverty,
malnutrition, diseases, separation from parents, loss of school etc
etc
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How to Reach In homes Anganwadis Construction sites Slums
Day-care-centres Creches Follow up clinics
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the reality and the inequity
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Can be enrolled for Child to Child Education programme ! Little
Mothers !
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What needs to be done Policy and Action Implications Ongoing
care from the beginning of pregnancy through the birth of a child
and into adolescence particularly the girl child Antenatal care
Perinatal care Early detection and early intervention Provision of
child care support to working mothers Promote female literacy /
family education /life skills LIFE CYCLE APPROACH !
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Physical Motor Social Cognitive Emotional Sensory Child
Development ECD Multidimensional and Multifactorial
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EIP Teach mothers to interact and communicate better with their
children Teach mothers to interact and communicate better with
their children Provide information to parents on child management
and development Provide information to parents on child management
and development Provide appropriate expectations for children and
general social support Provide appropriate expectations for
children and general social support Enhance the child s
intellectual language and social competence Enhance the child s
intellectual language and social competence Remove external risk
factors Remove external risk factors Place children in
developmentally enriching settings Place children in
developmentally enriching settings Train parents in responsiveness
and effectiveness Train parents in responsiveness and effectiveness
Provide continuous positive redirection and focused building skills
Provide continuous positive redirection and focused building skills
The value and availability of early intervention programs The
benefits of EIP clearly depend on early detection and early
referral PED 96, 95, 97, 2001. PED REV 2000 & 2001 Optimize the
abilities of the families to meet the special needs of their
children Optimize the abilities of the families to meet the special
needs of their children
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Educational Neuro- protection Early intervention Early
education (advantage of cerebral plasticity) (All interventions to
promote normal development and prevent disability) organizational,
therapeutic, environment modifying measures Programs involving
parents most successful !! Health and nutrition Conducive
Environment
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Deprived of a stimulating environment, a childs brain suffers -
children who dont play much or are rarely touched adverse effects
on development Rich experiences produce rich brains Importance of
hands-on parenting An urgent need for well designed preschool
programs Importance of A Stimulating Environment
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Health Promotion Health Promotion: the science and art of
helping people change their lifestyle to move towards state of
optimal health Strengthen health systems by involving communities
in preventative public health interventions Change attitudes
towards the girl child
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Partnerships Government Department Health authorities &
Trust Primary Health care team Hospitals Professions allied to
medicine and early childhood education Local authorities Community
groups & Voluntary organizations Schools Mass Media Building
and connecting bridges It is partnership at different levels and
among different stakeholders including government, medical
associations, academics and civil society that is difficult to
realize. Key stakeholders
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Policy and Action Implications Universal immunization
Addressing malnutrition Most of these children can be successfully
treated at home with ready-to-use therapeutic foods (RUTF). Vitamin
A syrup to all children 9-59 months in priority states. Zinc
supplementation along with Oral Rehydration Salts (ORS) for the
treatment of childhood diarrhoea in priority states. Iodized salt
compulsory, cheap. Double fortified salt (DFS), iodine and iron,
for the most vulnerable. Expand iron and folic acid (IFA) programs
for preschool children, adolescent girls, pregnant and lactating
women. Wheat flour fortification, Micronutrient supplementation
programs.
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Convention on the Rights of the Child 20th anniversary - 20
November 2009, Signed by every country in the world, and currently
ratified into law by all but two Activities covered Exclusive
breastfeeding Vaccines, Routine immunization Malaria prevention
Micronutrient Supplementation Improved drinking water Primary
school enrolment and completion Gender parity in primary education
Reduction of HIV prevalence and HIV treatment Child protection as a
holistic concept, offering children the right to be safeguarded
against a broad spectrum of violence, exploitation, abuse,
discrimination and neglect
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ICDS Launched on 2 nd October 1975,, ICDS Scheme worlds largest
programmes for early childhood development.. Objectives: Improve
the nutritional and health status of children in the age-group 0-6
years; Lay the foundation for proper psychological, physical and
social development of the child; Reduce the incidence of mortality,
morbidity, malnutrition and school dropout; Achieve effective
co-ordination of policy and implementation amongst the various
departments to promote child development; and Enhance the
capability of the mother to look after the normal health and
nutritional needs of the child through proper nutrition and health
education
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ICDS Services: Supplementary nutrition, Immunization, Health
check-up, Referral services, Pre-school non-formal education and
Nutrition and health education
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Helping children with special needs
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Children With Special needs Learning
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Conclusions Under three children are in the critical phase of
development and are vulnerable in the context of being at risk.
Reaching this age group has many challenges. Infants cannot be
considered in isolation, involvement of parents particularly
mothers, and even grandparents is extremely important. Early
comprehensive intervention programmes are required. Female
literacy, health, family education, and parenting skills are
important issues. Building partnership between stake holders is
essential for any meaningful action.