Final-Public-Health-Concern-of-Child-Health.pptx

In 2015, The World Health Organization (WHO) estimated that pneumonia, diarrhea, malaria, injuries,
and measles were major causes of deaths in the postnatal period, and prematurity, birth-related
complications, and neonatal sepsis were the leading causes of neonatal deaths. Although substantial
progress has been made in child survival in the last few decades, the United Nations Inter-agency Group
for Child Mortality Estimation (UN IGCME) estimated that approximately 5.6 million children died
before their fifth birthday in 2016 (UN IGCME 2017). Among those, 2.6 million (46%) died during the
neonatal period. Globally, the under-5 mortality rate (U5MR) dropped from 64 deaths per 1,000 live
births in 2006 to 41 in 2016. Likewise, neonatal mortality rates (NMR) also dropped from 26 per 1000
live births in 2006 to 19 per 1000 live births in 2016. Sub-Saharan Africa and Southern Asia were the
geographic areas where 80% of the total under-5 deaths and neonatal deaths occur (UN IGCME 2017).
According to the WHO, the leading causes of death among children under age 5 in 2016 were preterm
birth complications, pneumonia, birth asphyxia, intrapartum complications, congenital anomalies,
diarrhea, and malaria (WHO 2017). The discrepancy in child mortality was also observed by geography,
sex, and socioeconomic status (UN IGCME 2017).
According to the Department of Health Services (DoHS) annual report 2016/17, diarrhea, upper
respiratory tract infections, lower respiratory tract infections, fever (typhoid and para-typhoid), anemia,
protein-energy malnutrition, pneumonia, injury, birth asphyxia, and sepsis were the top ten illnesses in
under-5 children that lead to hospital admission in Nepal (DoHS 2016/17). The Nepal Demographic
and Health Survey (NDHS) 2016 has explored the prevalence of fever, diarrhea, and symptoms of acute
respiratory infection (ARI) in Nepal and reported that 21.0% of children had fever, 7.6% had diarrhea,
and 2.4% had ARI symptoms 14 days before the day of the survey. According to the same report, the
NMR of Nepal was 21 per 1,000 live births, while the under-5 mortality was 39 per 1,000 live births.
The NDHS 2016 revealed that nearly a third of the causes of neonatal mortality in Nepal were
respiratory and cardiovascular disorders (31%) and complications of pregnancy, labor, and delivery
(30%), followed by infection specific to the perinatal period (16%), congenital malformations and
deformations (7%), hypothermia (4%), sudden neonatal death (6%), disorders related to the length of
gestation and fetal growth (2%), and others (5%) (MoH, New ERA, and ICF 2017)

1. Public Health Concern of Child Health

2. Introduction: Child health is defined as the health of children younger than 5 years (Perinatal <7days old, neonate <29 days old, infant <1 year, child health <5 years of age). Child health is the physical, mental, emotional, and social well-being of children from infancy to adolescence. It includes a variety of topics including as good nutrition, regular medical care, vaccines, healthy development, illness prevention and treatment, and the establishment of a safe and caring environment. Ensuring child health requires addressing issues such as maternal health, family and community practices, and access to appropriate healthcare services.

3. Child developmental milestones

4. Childhood as crucial stage of healthy individual development Early childhood spans from conception to eight years, though in Nepal, the focus is on children up to five years old. According to various research on neurology, early childhood is an extremely important phase for children's growth and development, as the human brain develops at its fastest pace during these formative years of life. According to UNICEF (2016), a three-year-old child’s brain is twice as active as that of an adult, whereas neurons form new connections at the rate of 700 to 1000 per second. These connections determine children's physical and mental health, their lifelong learning and adaptability to change, and also their psychological resilience. According to Scientists, 90% of brain development occurs within the first five years, emphasizing the importance of early childhood. Childhood is a crucial stage of rapid physical, cognitive, emotional, and social growth that builds the foundation for future well-being and success. Proper nutrition, healthcare, and caring surroundings during children are critical for both physical health and the development of social and emotional abilities, laying the foundation for a healthy future. Given the importance of childhood development, it's crucial to provide a nurturing and safe environment. Investing in early education, healthcare, and parental support promotes children's well-being and sets the foundation for a successful future.

5. Child health and nutrition Nutrition is the foundation for the health and development of children and adults. Better nutrition is related to improved infant, child and maternal health, stronger immune system, safer pregnancy and child birth. Nutrition interventions are cost effective, high quality and essential investments which contribute towards the achievement of many of the Sustainable Development Goals.

6. Global: Child Nutritional Status Globally in 2022, 149 million children under 5 were estimated to be stunted (too short for age), 45 million were estimated to be wasted (too thin for height), and 37 million were overweight or living with obesity. Nearly half of deaths among children under 5 years of age are linked to undernutrition. These mostly occur in low- and middle-income countries. The developmental, economic, social and medical impacts of the global burden of malnutrition are serious and lasting, for individuals and their families, for communities and for countries. Source: WHO

7. National: Nutritional Status of Under 5 Children Percentage of children under age 5 who are malnourished Indicators Status (%) Target NDHS 2022 WHA 2025 SDGs 2030 Stunting among U 5 Children 25 24 15 Underweight among U5 Children 19 15 10 Wasting among U 5 Children 8 <5 4

8. Nutritional Status of Under 5 Children Percentage of children under age 5 who are stunted by province Stunting in children by household wealth: Stunting is nearly threefold higher among children from the lowest wealth quintile (37%) than among children from the highest wealth quintile (13%)

9. Major nutritional problems in Nepal Malnutrition, in all its forms, includes under nutrition (wasting, stunting, underweight), inadequate vitamins or minerals, overweight, obesity, and resulting diet-related non communicable diseases.   The main types of malnutrition seen in Nepal are  Protein-energy malnutrition, Iron deficiency anemia  Iodine deficiency disorders, and  Vitamin A deficiency

10. Factor affecting nutritional status Socio-Economic Factors Poverty: Limits access to sufficient and nutritious food due to economic constraints. Education: Low parental education reduces awareness of nutritional needs and proper feeding practices. Employment and Livelihoods: Seasonal employment and underemployment affect income stability and food security. Food Security: Geographical isolation and inadequate infrastructure hamper food availability and accessibility. Cultural and Social Factors Dietary Practices and Food Choices: Traditional diets often lack nutrient density and may be influenced by cultural taboos. Breastfeeding and Weaning Practices: Inadequate practices lead to early cessation or delayed introduction of solid foods. Gender Disparities: Food distribution and nutritional status may favor males over females within households.

11. Health-Related Factors Healthcare Access: Limited access to quality healthcare services, especially in rural areas. Infectious Diseases: High prevalence of diseases like diarrhea and respiratory infections affects nutrient absorption. Water, Sanitation, and Hygiene (WASH): Poor access to clean water and sanitation increases risk of infections. Environmental and Policy Factors Agricultural Practices: Low productivity due to traditional farming methods and lack of modern technology. Climate Change and Natural Disasters: Frequent natural disasters disrupt food production and supply chains. Government Policies and Programs: Effectiveness and reach of nutrition programs and health policies impact nutritional status. Infrastructure and Accessibility Transportation and Logistics: Poor infrastructure limits access to markets and healthcare facilities. Market Access: Limited access to diverse and affordable foods in local markets. Demographic Factors Population Growth and Urbanization: Strains on food and healthcare resources, with urbanization leading to unhealthy dietary patterns.

12. National Nutritional Program The GoN is committed to meeting the internationally agreed World Health Assembly (WHA) global nutrition targets by 2025, as well as Goal 2 of the Sustainable Development Goals (SDG) of achieving zero hunger by 2030. Scaling up Nutrition (SUN) initiative calls for multisectoral action for improved nutrition during the first 1000 days of life, Nepal joined the initiative on May, 2011. Nepal adopted the Multi-sector Nutrition Plan in 2012 with a 10-year vision (2013-2022) and five-year plans (2013-2018) to reduce chronic under nutrition with a focus on children in their first 1,000 days of life. The Constitution of Nepal (2015) ensures the right to food, health and nutrition for all citizens.

13. National Health Policy 2076 stated “ i mproving nutrition, discouraging contaminated and harmful foods promotion, production, use and access of quality and healthy food will be expanded.” “End hunger, achieve food security and improved nutrition and promote sustainable agriculture” is stated in the SDGs –Goal 2   In 2012 the World Health Assembly endorsed a comprehensive implementation plan on maternal, infant and young child nutrition, which specified a set of global nutrition targets to be achieved by 2025 (as compared to the NDHS 2011 baseline levels):     Achieve a 40% reduction in the number of children under-5 who are stunted. Achieve a 50% reduction of anemia in women of reproductive age.   Achieve a 30% reduction in low birth weight; ensure that there is no increase in childhood overweight.  Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%.  Reduce and maintain childhood wasting to less than 5%

14. National Nutritional Program Goal:  To achieve nutritional well-being of all people to maintain a healthy life to contribute in the socio-economic development of the country, through improved nutrition programme implementation in collaboration with relevant sectors. Strategies: Multi-sectorial nutrition policy and programs including food security will be updated and implemented with high priority. Short-term, medium-term, and long-term measures will be adopted at all levels with an emphasis on food diversification and balanced diet to improve the micro-nutrition status of different age groups including women and children. Programs will be developed and operated by strengthening school health programs and nutrition education. Domestic production will be promoted by encouraging the consumption of various nutritious and healthy foods.

15. Modality of implementation of nutrition program/services Nationwide programme Maternal, Infant and Young Child Nutrition (MIYCN) Growth Monitoring and Promotion Biannual distribution of Vitamin A and Albendazole Adolescent Nutrition Programme Control and Prevention of Iodine Deficiency Disorders (IDD) School Health and Nutrition Program Integrated Management of Acute Malnutrition Scale up programme Mother Baby Friendly Hospital Initiative (MBFHI) Nutrition Rehabilitation Center (NRC) Comprehensive Lactation Management Center Mother and Child Health and Nutrition Programme (MCHN) in Jumla , Dolpa , Mugu, Kalikot and Humla districts of Karnali Province and Solukhumbu district of Koshi Province Pilot programme Management of Moderate Acute Malnutrition programme in Siraha of Madhesh Province .

16. Control of PEM Promote breastfeeding within one hour of birth and avoid pre lacteal feeding. Promote exclusive breastfeeding for first six months and the timely introduction of complementary food. Ensure continuation of breastfeeding for at least 2 years and introduction of  appropriate complementary feeding after 6 months. Strengthen the capacity of health workers and medical professionals for nutrition and breastfeeding management and counselling.   Distribute fortified foods (super cereal, fortified rice) to pregnant and lactating women and children aged 6 to 23 months in food deficient areas.  Create awareness of the importance of additional dietary intake during pregnancy and lactation.

17. Household food security: Promote kitchen garden and agricultural skills. Promote raising of poultry, fish and livestock for household consumption. Inform community people how to store and preserve family food. Improve technical knowledge of food processing and preservation. Promote women’s group for income generating activities. Improved dietary practices Conduct a study to clarify the problems of culturally-related dietary habits Promote nutrition education and advocate for good diets and dietary habits. Develop and strengthen programmes for behaviour change to improve dietary habits. Strengthen nutritional education and advocacy activities to eliminate food taboos that affect nutritional status.

18. Infectious disease prevention and control Promote knowledge, attitudes and practices that will prevent infectious diseases. Ensure access to appropriate health services. Improve nutritional status to increase resistance against infectious disease Improve safe water supplies, sanitation and housing conditions. Improve food hygiene. School Health and Nutrition Programme Build capacity of policy and working level stakeholders. The biannual distribution of deworming tablets to grade 1 to 10 school children. Celebrate School Health and Nutrition (SHN) week in June every year to raise awareness on importance nutrition at the community level through school children and health workers. Introduce child-to-child and child-to-parent approaches.

19. Growth monitoring and promotion The Government of Nepal prioritizes monthly growth monitoring for children under 2 years to ensure proper nutrition, providing counseling and referrals if needed. In FY 2079/80, 78.9 % of children aged 0-23 months registered for the growth monitoring, out of total who attended for GM session, 2.7% were suffering from underweight at national level. The national average for the number of visits is only six visits in FY 2079/80 which is only 25% of the ideal 24 visits. Sudurpaschim has the highest average number visits of 10.5 followed by Karnali (9.5), Lumbini (9) and Gandaki (7.5).

20. INFANT AND YOUNG CHILD FEEDING PRACTICES Optimal infant and young child feeding (IYCF) practices are critical to the health and survival of young children. The national average of newborns initiated with breastfeeding within one hour of birth was 84 % in FY 2079/80. The exclusive breastfeeding rate increased at national level from 36.9% in 2077/78 to 54.9 % in 2079/80. The rate of timely introduction of complementary foods increased by 19.3% in FY 2079/80 ( 55 %) as compared to last FY.

21. Trends in exclusive breastfeeding Exclusive breastfeeding has fluctuated over time, with a sharp dip in 2006. However, exclusive breastfeeding has been steadily declining since 2011, from 70% to 56%.

22. Multiple Micronutrient Powder (MNP) (Baal Vita) Community Promotion Program The program targets children aged 6-23 months, providing 60 Baal Vita sachets every six months. Baal Vita contains 15 micronutrients, including iron and zinc, to combat iron deficiency anemia. Families mix one sachet daily into the child’s food for two months and collect new sachets every six months from local health institutions or community health volunteers. In FY 2079/80, national coverage of the MNP use of at least one cycle among 6-23 months’ children has increased from 29.6% in FY 2078/79 to 40.9% in FY 2079/80. The three cycle coverage has also increased from 2.8 in FY 2078/79 to 5.1 in FY 2079/80. Data revealed that the returning back of users/guardians to the facility for the second batch of MNP is very poor.

23. Integrated Management of Acute Malnutrition (IMAM) The Integrated Management of Acute Malnutrition (IMAM) Program provides treatment for children aged 0-59 months with Severe Acute Malnutrition (SAM) through inpatient and outpatient treatment services at health facility and community levels. The IMAM program aims to integrate across health, early childhood development, WASH, and social protection sectors for the continued rehabilitation of SAM cases and to widen the reach of malnutrition prevention programs and services.

24. Community mobilization for IMAM 3,623,283 children were screened by FCHVs throughout the country using MUAC tapes for their nutritional status. Among the screened children, 2.3% were found to be undernourished, Moderate Acute Malnutrition(MAM) (2.1%), Severe Acute Malnutrition (SAM) (0.2%) at national level. Outpatient therapeutic center (OTC) services In FY 2079/80, total 9,760 children from 6-59 months with SAM admitted in OTC. Inpatient therapeutic center In FY 2079/80, a total of 798 cases took services from Inpatient therapeutic center (ITCs) with highest contribution of 515 cases from ITCs in Madhesh Province. Nutrition rehabilitation center There is a total of 26 Nutrition rehabilitation center (NRCs), three each in five provinces, four in Sudurpaschim and five in Bagmati provinces. There were two deaths (0.09%) among 2042 cases admitted in NRCs)

25. Control and Prevention of Iron Deficiency Anemia Control parasitic infestation among nutritionally vulnerable groups through deworming pregnant women and children aged 12-23 months •Multiple micronutrient supplementation for children aged 6-23 months. 43% of children age 6–59 months are anemic, including 25% who are mildly anemic, 18% who are moderately anemic, and less than 1% who are severely anemic.(NDHS 2022) Anemia in children is highest in Madhesh Province (51%) and lowest in Gandaki Province (31%)

26. Prevalence of anemia in women 34% of women are anemic, including 18% who are mildly anemic, 15% who are moderately anemic, and 1% who are severely anemic.   Women living in the terai ecological zone are more likely to be anemic (45%) than those living in hills (20%) and mountain (23%) regions. More than half of the women (52%) are anemic in Madhesh Province, which is in the terai ecological zone.  Trends: The prevalence of anemia among women age 15–49 increased from 36% in 2006 to 41% in 2016 and declined to 34% in 2022. (NDHS 2022)

27. Coverage of 180-day supply of Iron Folic Acid during pregnancy There was 55.4% coverage of the 180-day supply of IFA during pregnancy in FY 2079/80.

28. Coverage of 45-day supply IFA to postpartum mother The coverage of 45-day supply of IFA to postpartum mothers was 74.5% nationally with five provinces surpassing the national average- Sudurpaschim (97.5%), Karnali (96.4%), Lumbini (86.8%), Madhesh (84.2%) and Gandaki (77.7%), in FY 2079/80.

29. Control and Preventions of Vitamin-A Deficiency Disorders The biannual distribution of Vitamin A to children aged 6-59 months is facilitated by FCHVs through campaigning, the distribution occurs twice a year, specifically on Baisakh 6th and 7th and Kartik 2nd and 3rd. The government initiated the National Vitamin A Programme in 1993 to improve the vitamin A status of children aged 6-59 months and reduce child mortality. Postpartum vitamin A supplementation for mothers within 42 days of delivery In Kartik 2079, national coverage of Vitamin A was 98.3%, which decreased to 93.9% in Baishak 2080.

30. Control of Intestinal Helminths Infestations The coverage of the deworming was 98.0% in Kartik and dropped by 11.7% point in Baishak (86.3%) in FY 2079/80.

31. Control and Prevention of Iodine Deficiency Disorders (IDD) To address IDD, MoHP initiated a policy in 2029/30, mandating the fortification of all edible salt through universal salt iodization. GoN employs the Two-Child-Logo to certify adequately iodized salt, and DoHS utilizes a social marketing system to enhance awareness and promote household usage.

32. National survey reports reveal a substantial increase, with the percentage of households using adequately iodized salt rising from 55% in 2054/55 to 98% in 2078/79.

33. The major challenges for Nutrition programs Nutrition and Food Security Steering Committees (NFSCC), MoHP platforms/ committees and Health Facility Operations and Management Committees (HFOMC) are established to discuss the nutrition and health systems but are not functioning effectively. Federal, Provincial and Local level governments need coordination, cooperation and collaboration to implement nutrition activities and other health related components. This has increased duplication of activities whereas there is a gap in effective implementation of nutrition activities. GMP, IMAM, MNP and Adolescent IFA are key nutrition specific interventions. The coverage, compliance and quality of service is found to be poor. PHC/ORC and Health Mothers Group Meeting are community-based sites for nutrition and other health activities, but they are not functioning effectively and lack family based nutrition specific interventions. The trend of early initiation and exclusive breast feeding is decreasing whereas the trends of bottle feeding is increasing.

34. The number of OTC has been increased but the coverage is minimal. Active screening for early diagnosis is not prioritized. ITC/SC has not been implemented effectively. Limited allocation of financial resources, delay in disbursement and inefficient utilization. Deep-rooted misconceptions, taboos and harmful socio-cultural practices related to food and nutrition. Emerging issues of the triple burden of malnutrition (undernutrition, overweight/obesity, and micronutrient deficiencies) Recording and reporting of nutrition program indicators within HMIS is inconsistent, incomplete, untimely, and unreliable for data centric planning. Procurement and supply of nutrition commodities (RUTF, MNP, IFA) is not timely. The transportation and storage of nutrition commodities at local levels is not satisfactory.

35. Way Forword: Scaling up of comprehensive nutrition services at all levels ensuring equitable access and provision of nutrition services for all children, adolescents and women of reproductive age. Promote and support breastfeeding through harmonized laws, breastfeeding corners in workplaces/public spaces, and advocacy for paid maternity leave during the exclusive breastfeeding period. Improve multisector coordination and collaboration and incorporation of the private sector in the provision of nutrition services. Analyze the effectiveness of micronutrient programs, including transitioning from IFA to Multiple Micronutrient Supplementation during pregnancy, and adopt sustainable approaches like large-scale food fortification to improve dietary quality.

36. Strengthen the capacity of institutions and human resources to deliver quality services. Strengthen nutrition information management systems to ensure quality data generation through timely and correct recording and reporting along with the implementation of Routine Data Quality Assessment (RDQA) at all levels. Strengthen logistics management of nutrition commodities to ensure a well-functioning supply chain. Intensify Social Behavior Change Communication to promote recommended nutrition behaviors. Scaling up of nutrition friendly health facility concept to all health facilities. Strengthen and scale up the Mother and Baby Friendly Hospital Initiatives (MBFHI) to all applicable hospitals and health facilities. Strengthen the School Health and Nutrition Program.

37. Improve maternal nutrition through effective counselling during ANC visits, micronutrient supplementation and follow up visits by FCHV through health mother’s groups and home visits. Strengthen the nutrition in emergency preparedness, response and recovery mechanism. Integrate nutrition in universal health coverage. Promote the consumption of locally available nutrient dense foods. Advocate for adequate budget allocation for the nutrition program at all levels along with budget analysis and tracking.