Care for child

One of the common worries of a mother is about the adequacy of her child’s diet. A child requires more calories and protein for growth and tissue repair. If the child does not get adequate nutrition during this period, overall growth of the child is affected. Eating habits are always set in the first few years of life. That is the time to ingrain a healthy eating pattern in children. Velocity of growth varies in different age and sex group. Child’s nutritional requirements do vary accordingly.

How to make eating enjoyable?

There must be regularity in meal times. In between munching must be discouraged. There is no need to worry about occasionally not eating a meal properly or about over eating. It is perfectly normal. There must be some changes in the menu and the environment, otherwise it will become monotonous. Try to make food more appealing by using appropriate flavouring agents and syrups. There is no point in forcing a child to eat; this will make a child rebellious. Try avoiding discussing about each ones likes and dislike regarding food while eating. The difficulty to make your child eat vegetables can be overcome by catering to the taste in colour and texture. When introducing new foods try offering one at time and give small amounts at first. It is a good idea to try out new foods at the beginning of the meal while a child is still hungry. A little imagination in preparation and serving can be very rewarding. When you do all this, you must be cautious not to encourage your child’s pranks.

Food for 0 – 3 months

The best food for the newborn baby is mother’s milk. Breast milk is free from contamination and adulteration and supplies nutrients in almost correct amounts and propositions needed by the infants. It also provides an opportunity for close contact and emotional satisfaction of both mother and child. Breast milk contains immunoglobulin’s (protective proteins) that protect the child to some extent against infections.

Some mothers practice giving boiled water, fruit juices or glucose water, which is not essential. With breast milk there are less serious illness and allergies. Babies who were breast-fed have lesser chance of developing asthma in later life. The infant of less than 34 weeks has poor sucking and swallowing reflexes. In such cases expressed breast milk can be given.

During the first 3 months the mother’s diet should be given great importance. She must have a well balanced diet. Major handicap of breast milk is deficiency of iron. Till three months of age iron store in the baby is sufficient for the requirement. After three months iron has to be supplemented.

Food for 3 – 6 months

Nutritional supplementation starts during this period .The infants diet pattern is gradually changed from exclusive breast milk to breast milk with cooked solid foods. One can start supplementation with cereal foods provided the food is cooked soft and mashed to a thin consistency.

The new foods should be first introduced at lunchtime and extended gradually to other meals. When you start any food item give for at least one week, if possible two weeks before starting any another food item. Initially there may be mild indigestion.

Ragi powder, suji, and raw plantain powder can be cooked in milk with sugar and can be given. Make sure not to feed these in bottles, which will delay the child to eat the solid food and have more chances to develop lose motion. Rice can be cooked soft and mixed with curd and can be given. When child gets used to this, khichdi (rice and moong dhal) can be given. Soups and strained vegetables and fruits may be gradually introduced during the supplementation period. The fruits and vegetables will correct the deficiency of iron in breast milk. Fruit must be fully ripe.

The well nourished infant doubles his birth weight by 5 months of age

Diet for Children (1 To 6 Years)

A balanced and adequate diet is required to supply the nutrients and energy needed for the growing child. The requirement of all nutrients is increased, but the pattern of increase varies for different nutrients in relation to their role in growth of specific tissues.

A child of one year old can eat most of the dishes that are prepared for the rest of the family. They require less spicy food. The appetite normally decreases during this period. Fuzzy eating starts at this time so make sure the food is interesting and attractive. They need five to six meals a day because of their smaller appetites. Healthy foods such as whole wheat bread, cereals, fruits and vegetables should make up the major part of the diet of the children. Foods such as meat, fish, soya products, milk, pulses and cereals will provide the protein necessary for this age group.

Under 5 year old children should not use skimmed milk to restrict on fat and cholesterol as they need the extra calories, but grilled and baked foods are always preferable to fried and fatty ones. The growth rate of the child is slow in this group.

Protein has a very important role in the diet of the preschool child because there is considerable increase in muscular development during these years. The requirements for essential amino acids are higher for children than adults. So protein should be selected from complete protein foods such as milk, egg and meat.

The calorie requirements are also increased due to the high cellular activity. Whole grains or enriched cereals increase the calories. Concentrated sweets and foods that are very high in fat should be avoided.

Vitamins and minerals must be supplemented adequately. Calcium and iron requirements are relatively greater during early childhood. Deficiency of calcium can affect the bones of growing children. Foods rich in calcium such as milk and milk products, ragi, green leafy vegetable and fish should be included in the diet of children.

Aneamia, a common medical problem seen during this period is due to dietary lack of iron and / or by hookworm infestation. To meet this increased need for iron, iron rich foods, like rice flakes, green leafy vegetables, egg, and liver should be included in the diet. Preferably food must be given after children enjoyed his or her favorite activities such as TV programs or games to avoid them rush to leave the table.

Can a child eat Sweets and Candies

Let your children have occasional sweets. It is not going to cause much harm if taken in moderation. The draw back of excessive consumption of sweets and candies are it spoils the appetite and cause tooth decay. Sweet containing fermentable carbohydrate which adheres to the tooth surface is the major dietary factor influencing tooth decay. The greater cariogenic effect depends up on longer the sugar stays in the mouth. This is due to stickiness of the carbohydrate. Encourage children to brush their teeth before and after going to bed. Ice cream and cakes are marginally better than hard candies because there are at least some nutrients in the milk and grains.

Tips to help your child develop good eating habits

(1). Encourage your child to eat slowly and chew the food properly.

(2). Eat meals with the family as often as possible.

(3). Discourage eating while watching TV.

(4). Encourage Healthy Snacks.

(5). Include a variety of delicious healthy foods for meals and snacks.

(6). Set a good example for your children by eating a healthy and balanced diet.

(7). Don’t place your children on any restrictive diet with out proper supervision.

(8). Do not use food to punish your child.

(9). Occasional change of place and crowd will over come the monotony.

(10). Regularity in meal timing is essential.

(11). Tea and coffee should be restricted as they over stimulate the system.

(12). Salads can be made interesting for them by adding crushed peanuts or incorporating in sandwiches.

(13). Encourage children to enjoy fruits and vegetables by giving them different varieties from an early age.

(14). Do not add unnecessary sugar to drinks and foods.

(15). Don’t give skimmed milk to less than five year old.

(16). Don’t give whole nuts to children under four years old since they may choke.

It is important to realize that a healthy, balanced diet in childhood will go a long way in ensuring your child stays healthy later on in life.

The main causes for problems like high blood pressure are:

Poor Diet

Lack of exercise

What should your child eat? Your child should have foods rich in fibre. For breakfast, your child can have two toasted slices of wheat bread or brown bread with mayonnaise or any other topping your child prefers, along with a glass of milk. Try and use fresh ingredients always. Use homemade mayonnaise so you can make sure you use good excellence ingredients.

You could also alternate milk with a glass of lassie in the summer. Curd is better than milk, unless you are sure of the quality of the milk you are giving your child.

Physical development milestones

(1). Ability to lift and control the orientation of the head

(2). Crawling begins

(3). Walking begins

(4). Speech begins

(5). Voice lowers in pitch (especially noticeable in boys)

(6). Pubic hair appears

(7). Genitals and reproductive organs mature

(8). Menses begin (females)

(9). Body hair and facial hair appears

(10). Infant Feeding 0-4 months

What is the ideal food for babies?

Breast milk is the ideal food for your baby. The baby till 4-5 months of age requires no other food as breast milk is the only “standard” food for the infant.

What are the advantages of breastfeeding?

(1). It is safe, hygienic, and available to the infant at the correct temperature.

(2). It meets the nutritional requirements of the infant fully in the first few months of life.

(3). It contains antimicrobial factors that provide protection against diarrhoeal diseases and respiratory infections in the first months of life.

(4). It is easily digested and utilized by both normal and premature babies.

(5). Promotes bonding between the mother and infant.

(6). Helps development of the jaws and teeth of the baby due to suckling.

(7). Protects babies from obesity.

(8). Prevents malnutrition and reduces infant deaths.

What are the feeding patterns?

Introduction to bottle

Most babies do not need to be bottle fed at any stage. After exclusive breast feeding till 6 months a feeding cup or glass can be introduced.

Night feeding

The baby is breastfed on demand. After the age of 3 months usually around 5-6 kgs.weight, if the baby stops waking at night frequently sleeping often for 6 hrs. At a stretch. Once weaning starts and solids are introduced a baby may sleep for as long as 8-10 hrs at a stretch.

Weaning – 6 months onwards

This is the period of the introduction of foods in the child’s diet i.e. called the weaning process. Foods such as fruits, vegetables and pulses and cereals are introduced slowly, one food at a time.

When and how to start weaning?

The first semi-solid foods are normally introduced at 6 months of age. It is important to make this transition to semi-solid foods an enjoyable one. The amount of food offered and swallowed in the beginning is a teaspoon or so. Patience is needed when babies are first introduced to semi-solids. While they are learning to eat this way, they may often spit out the food – this does not mean that they dislike the food or are not hungry. It is normal for your baby to bring the food out, as the ability to chew and swallow takes time to develop. Infants believe the food better, if not distracted by other activities while feeding. Try to have flexible feeding schedules. After the first few weeks, a healthy infant will develop a self-regulated feeding schedule. The number of total feeds a day will usually reduce significantly by the time the infant is six months of age.

What are the qualities of weaning foods?

Breast milk is a complete food for the infant. Weaning foods are used as an additional source of energy as well as to satisfy the increasing requirements for all essential nutrients. Particular attention should be paid to proteins, iron, vitamin A and C, as these are frequently found to be deficient in the diet of young infants.

Desirable qualities of weaning foods:

(1). should have high energy content

(2). should be easy to digest

(3). should be semi-solid in consistency

(4). should not be too thick

(5). should be fresh and clean

(6). should not be expensive and should be easy to prepare

What are the guidelines during weaning?

(1). Give solid food only once in a day when you start weaning.

(2). Introduce only one food at a time to permit the infant to get used to it.

(3). Give very small amounts of any new food at the beginning, 1-4 tsp.

(4). Allow the infant to become familiar with the food before trying to give another.

(5). Use a very thin consistency when starting solid foods, slowly thicken consistency.

(6). If, after several trials, that baby has an acute dislike for a food, omit that item for a week or two and then try again. If the dislike persists it is better to substitute it with another.

(7). The child should be encouraged to try new flavours. Variety in choice of foods is important.

(8). Infants may object to taking some foods but will take them willingly if it is mixed with another food.

(9). No added salt or sugar is needed if sweetening is necessary, sweeten with fruit puree.

(10). Food should not be forced on the baby.

(11). Salt should not be added or added to salty foods.

(12). Added salt may actually be harmful, before the age of one year.

(13). When the baby accepts one slid feed in good amount (usually by 7 months age) introduced second solid feed.

(14). Breast milk should be continued and a total of 5-6 feeds (solid milk)are feeded slowly increased texture should be tolerated. Do not puree foods.

(14). Maintain breast feeding throughout the first year.

What is a balanced diet?

A diet which contains all the nutrients e.g. energy, proteins, fats, vitamins, minerals etc. required by a child for the proper maintenance of health and optimum growth is termed a ‘balanced diet’. Dals and beans have high contents of protein and a small amount of fat. Bread is rich in carbohydrates but poor in proteins.

What does the child need in his diet?

It is important that a child’s diet should be both good in quality as well as adequate in quantity. If his diet is deficient in nutrients and energy, it can adversely affect his weight gain and body growth. The child’s diet should supply him with proteins, carbohydrates, fats, vitamins, minerals and other nutrients in adequate quantities.

How to provide a balanced diet?

Between 6-12 months of age solid food does not provide complete nutrition but as the infant approaches 9 months solid foods form a major part of the dietary nutrients. At this age a baby should be having 3 solid meals, a variety of foods containing proteins fats and carbohydrates with enough fibre. Milk should be given only twice or maximum 3 times a day a total intake of 500-600 ml of milk is sufficient.

Breast milk can be gradually decreased and discontinued by the age of 12-15 months. Food patterns are developed near the beginning in life and it is important that good food habits be developed early. An inadequate intake of calories will result in poor weight gain and vitamin or ion deficiencies can result in anemia rickets or other diseases.

The postpartum period, or puerperium, starts about an hour after the delivery of the placenta and includes the following six weeks. Postpartum care should respond to the special needs of the mother and baby during this special phase (see tables 1 and 2) and should include: the prevention and early detection and treatment of complications and disease, and the provision of advice and services on breastfeeding, birth spacing, immunization and maternal nutrition.

Postpartum hemorrhage is the single most important cause of maternal death. It kills 150 000 women each year and nearly nine out of ten of these deaths take place within four hours of delivery. A woman who is anaemic is usually less able to cope with blood loss than a woman who is well nourished. During the first hours after the birth, the care-giver has to make sure that the uterus remains well contracted and that there is no heavy loss of blood. If the bleeding is chiefly severe blood transfusion may be the only way of saving a woman’s life.

Puerperal infections such as sepsis are still major causes of maternal mortality in many developing countries. Fever is the main symptom and antibiotics the main treatment, though prevention by ensuring cleanliness and hygiene at delivery is obviously the best course of action.

Eclampsia is the third most important cause of maternal mortality worldwide. A woman suffering from eclampsia or severe preeclampsia the first days postpartum should be hospitalized. The treatment of choice is magnesium sulphate.

Needs of newborn infants

In the postnatal period newborn infants need:

A. Easy access to the mother

B. Appropriate feeding

C. Adequate environmental temperature

D. A safe environment

E. Parental care

F. Cleanliness

G. Observation of body signs by someone who cares and can take action if necessary

H. Access to health care for suspected or manifest complications

I. Nurturing, cuddling, stimulation

Protection from

A. Disease

B. Harmful practices

C. Abuse/violence

Acceptance of

A. Sex

B. Appearance

C. Size

Other common postpartum complications include urinary tract problems such as infections, urine retention or incontinence. Many women also experience pain in the perineum and vulva for several weeks, in particular if there was tissue damage or an episiotomy during the second stage of labour. The woman’s perineum should be regularly inspected to make sure it is not infected.

Psychological problems in the postpartum period are also not uncommon. These problems can be lessened by adequate social support and support from trained care-givers during pregnancy, labour and postpartum period.

The nutritional status of the woman during adolescence, pregnancy and lactation has a direct impact on maternal and infant health in the puerperium. Women’s intake postpartum should be increased to cover the energy cost of lactation. The three main vitamin or mineral nutritional deficiencies in the postpartum period are iodine deficiency disorders, vitamin A deficiency and iron deficiency anaemia. The main causes of micronutrient malnutrition are inadequate intake of foods providing these micronutrients and their impaired absorption or utilization. Preventive and treatment measures include ensuring regular intake of appropriate foods, food fortification, giving supplements to pregnant and lactating women and infants and children.

The newborn’s health and well-being can also be affected by a variety of conditions. The most common causes of death and disability in the postnatal period include prematurity, neonatal sepsis, respiratory infections, neonatal tetanus and cord infections, congenital anomalies, and birth trauma or asphyxia. Babies that are preterm or have a low birth weight are more prone to low body temperature, more likely to succumb to infection, more often need to be resuscitated, and are more difficult to feed. Mothers and health workers can help avoid dangerous heat loss by making sure the room is warm and that the baby is kept next to its mother.

Infections are still a major threat to newborn infants in developing countries. Like puerperal sepsis in the mother, the extent can be reduced dramatically by making sure that the birth takes place in hygienic conditions and that those present observe basic rules of cleanliness such as hand washing.

Jaundice is quite common in newborns and usually clears up without treatment, but it can be especially dangerous in preterm or low birth weight babies. Ophthalmia neonatorum is a discharge from the eyes that occurs within the first two weeks of life but can be prevented by application of ointment or eye drops in the first hour after birth.

The establishment and maintenance of breastfeeding should be one of the major goals of postpartum care. Breast milk provides optimal nutrition for newborn infants, protects them against infections and allergies and promotes mother-infant bonding. The baby should be given to the mother to hold immediately subsequent to delivery, to provide skin-to-skin contact and for the baby to start suckling as soon as s/he shows signs of eagerness – normally within ½-1 hour after birth. In institutions babies should be kept with their mother and unrestricted breastfeeding should be allowed. Mothers need help and advice on how to breastfeed. extra feeds should be avoided.

During the postpartum period women need counselling on contraception. If the mother fully breastfeeds the baby she can, at least for the first six weeks, rely on the contraceptive effect of lactational amenorrhoea (LAM). If after 6 weeks an alternative contraceptive is required, methods include the progestin-only pill, a depot-medroxyprogesterone acetate (DMPA) injection, an intrauterine device (IUD), or barrier methods such as a diaphragm or condoms. Combined oral contraceptives should be avoided during the first months of lactation.

The postpartum period is an important opportunity to counsel women, their partners and their families about the decision to carry out an HIV test if the opportunity was missed during pregnancy. If a test is positive, counselling needs to be given on possible treatment or preventive measures. In many resource-poor settings, the risks of diarrhoeal disease or malnutrition due to improper or inadequate preparation of artificial milk outweigh the risk of contracting HIV through breastfeeding. Maternity services should take the necessary preventive measures to protect health care workers and mothers against infection.

All mothers should be immunized with at least two doses of tetanus toxoid to protect both themselves and their newborns. The third dose is given 6 months after the second and the last two doses are given after at least one year or during a subsequent pregnancy. Where there is a high risk of tuberculosis infection, BCG immunization should be given to infants soon after birth. Diphtheria-pertussis-tetanus vaccine is recommended for all children at 6, 10 and 14 weeks. A single dose of oral polio should be given at birth or within the first two weeks of life, and the normal polio immunization schedule should follow at 6, 10 and 14 weeks. Where perinatal transmission of hepatitis B is frequent, the first dose of hepatitis B vaccine should be given as soon as possible after birth and should be followed by further doses at 6 and 14 weeks.

Postpartum services should be based on the needs and health challenges outlined above, incorporate all the essential elements required for the health of the mother and her newborn, and should be provided in an integrated fashion. Skilled care and early identification of problems could reduce the incidence of death and disability, together with the access to functional referral services with effective blood transfusion and surgical capacity. With regard to timing of postnatal visits, there seem to be “crucial” moments when contact with the health system or caregiver could be instrumental in identifying and responding to needs and complications. These can be resumed in the formula (which should not be interpreted rigidly) of “6 hours, 6 days, 6 weeks and 6 months”. Table 3 below summarizes the broad lines of care that can be offered at each point of contact during the puerperium. More important than a rigid but unfeasible visiting schedule is the possibility for all women to have access to a health care provider when she needs it.

There is a need to provide a solid infrastructure for the provision of a service which is comprehensive, culturally sensitive and which responds to the needs of childbearing women and their families. Elements of this infrastructure include policy, service and care provision, tool development, training and human resource issues, health protection and promotion and research.

National Neonatology Forum in collaboration with the Govt. of India, Ministry of Family Health and Welfare (MOFHW) and UNICEF is celebrating “Newborn Week” between 15th - 21st November`2001.

Key elements of postpartum care

6-12 hours	3- 6 days	6 weeks	6 months
Baby: breathing warmth feeding cord immunization	feeding infection routine tests	weight/feeding immunization	development weaning
Mother: blood loss pain BP advice/ warning signs	breast care temperature/infection lochia mood	recovery anaemia contraception	general health contraception continuing morbidity

(1). What are the common causes of newborn deaths and are they preventable?

The common causes of newborn deaths in our country are:

A. Infection – 52%

B. Asphyxia or lack of oxygen to fetus and newly born baby – 20%

C. Prematurity, babies born much before completing 9 months of pregnancy – 15%

D. Congenital malformations, birth defects and other miscellaneous causes – 13%

Most of these are preventable to a large extent.

(2). What are low birth weight babies and why are they special?

Babies born with a birth weight of less than 2500g are low birth weight babies (LBWB), those with birth weight less than 1500gms are very low birth weight babies (VLBW) and those with a weight of less than 1000gms are extremely low birth weight (ELBW). In India nearly one third of all newborn babies have low birth weight.

The common causes of low birth weight babies are:

A. Frequent pregnancies

B. Poor care during pregnancy

C. Poor nutritional status of mother

D. High blood pressure, anemia, infections

E. Tobacco use by mother

F. Low maternal literacy

G. Pregnancy at young age

A large number of the above mentioned predisposing factors for low birth weight babies can be prevented by health education. Maternal nutrition plays an important role in newborn health. Keeping this in mind the stress is on increasing awareness amongst the public, health personnel regarding the importance of nutritional status and health of the girl child, the future mother. “Every delivery to be attended by trained personnel”.

(3). What can be done to improve the outcome of newborn babies?

A. Education of expectant mothers about various problems during pregnancy which can affect the baby.

B. Basic minimum care during pregnancy, nutrition counseling and supplementation of iron and vitamins.

C. Preferably deliveries to be conducted at the institution or by trained medical personnel. All high-risk pregnancies where problems are anticipated should be conducted at hospitals or institutions.

D. Provide essential care to all newborn babies.

E. Early diagnosis of problems in newborns and early referral to hospitals for optimum care and treatment.

F. Transportation of newborn babies should be such that the baby doesn’t become cold during transfer.

(4). Essential newborn care

A. Good antenatal care, maternal nutrition, prevention and treatment of anaemia and tetanus toxoid immunization to the mother.

B. Delivery conducted by trained personnel.

C. Prevention and early treatment of infections.

D. Recognition of danger signs of disease and early referral to a medical facility.

E. Stable and safe transport.

F. Resuscitation of newborn.

G. Gives warmth to the newborn baby i.e. to prevent baby becoming cold.

H. Early and elite breast feeding for 6 months.

Symptoms and Treatment

The rotovirus is a viral infection found in babies and young children. Symptoms of the illness include diarrhea, vomiting, nausea and fever. The virus acts by attacking the lining of the small intestine. This results in dehydration from extreme loss of fluids and electrolytes. Often these symptoms will last from three to ten days. Children infected with the rotavirus can be contagious for ten to twelve days following the first signs of diarrhea. Home treatment consists of rest and administration of specially made electrolyte substitute products. Examples of these include gastrolyte, pedialyte and plamalyte.

Oral thrush is an infection caused by the yeast fungus known as Candida albicans. It is also called candidosis or moniliasis, but usually these terms describe the appearance of infection in adults (candida albicans). Oral thrush often finds its way into the human body when the immune system is in a weakened state. Newborn babies are particularly at risk from infections such as oral thrush. Two specific causes of oral thrush are a reaction to antibiotics and transmission from a mother with a yeast infection. The main symptom of oral thrush is evidence of painful white lesions on the inside of the mouth. When oral thrush or a yeast infection has been diagnosed, both the mother and her baby should be treated simultaneously. The infection is usually treated with Nystatin.

Like oral thrush, ringworm is a fungal infection of the skin. It generally affects the scalp in a condition called tine capitis. When the fungal infection is present on the body it is referred to as tinea coporis. Symptoms of a ringworm infection in infants include coin-sized scaly patches. These rashes may be dry or moist and generally stop growing once they are an inch in diameter. Ringworm on the scalp may look like bald spots or scaly patches with hair broken off in the center. Sometimes ringworm is inappropriately confused with cradle cap. Treatment for ringworm should begin by consulting with your pediatrician. He or she will most likely propose an over-the-counter anti-fungus cream. Further prevention of reinjection includes carefully washing your baby’s bedding until the infection is completely cleared up.

Cradle cap is a common scalp and skin condition caused by excess oil production from the scalp. Symptoms contain flaky, scaly or greasy crusts on the scalp, ears or eyebrows of an infant. Cradle cap can be treated by first loosening the crusts. Using baby, mineral or olive oil, gently rub the crusts for ten minutes followed shortly by shampooing. Comb the hair in one direction with a baby comb, warily removing crust remnants as you go. You should then shampoo your child’s hair three times a week during the first three weeks following the treatment. Afterwards, use the anti-dandruff shampoo once a week until the cradle cap is completely gone. If the condition worsens or begins to look infected you should immediately contact your pediatrician.

Cat scratch fever is a bacterial infection caused by the microorganism Bartonella henselae. It is most often caused from a scratch or bite from a cat or kitten. Symptoms of a cat scratch infection include small pimples forming around the wound as it heals. These pimples can last up to a month. Your baby’s lymph nodes may become swollen and tender. Other symptoms comprise headache, fever, poor appetite and fatigue. You can take preventative measures by cautiously cleaning scratches and bites from cats with soap and water.