NUTRITION AND HEALTH NEEDS OF THE CHILD

Chapter 1

Ensuring optimal health and

Early childhood (2 to 6 years) is one of the crucial periods of life characterized by
growth measuring head
substantial physical and psychological changes. Although the rate of growth slows
circumference heigh, weight
down during this period compared to infancy, the child continues to gain weight and
MUAC, Use of growth chart,
height. The weight of the child quadruples and height grows by two thirds.
malnutrition
Moreover, a remarkable growth of brain occurs during early childhood reaching 90%
of adult size (Tanner, 1978). Good nutrition is very essential to facilitate normal
growth and development of the children in this age group. However, under
Chapter 2 nourishment has been reported to be a very serious problem contributing to growth
failure among preschoolers in India, in spite of considerable economic development
Common childhood illnesses,
Prevention and and improved food production. This might be due to low quality of complementary
Management (Immunization foods fed to the child from infancy onwards, high burden of intestinal parasitic and
schedule) other infections, poor socioeconomic back ground, low birth weight (LBW) and
intrauterine growth retardation etc. (Kuklina EV et al, 2006). Diarrhoea, respiratory
diseases and infections such as measles are common health problems due to
malnutrition in this age group which further affect their nutritional status. Failure to
Chapter 3
achieve the genetically potential height is one of the repercussions of malnutrition
Nutrition importance of BF, resulting in stunting. Research has proved that impaired food intake during early
Complementary feeding, stages of life not only affects the immediate growth and development but might
Food of groups and balanced even affect their growth in later periods of life i.e. childhood and adolescence. In
meal planning, Safe handling addition to adversely affecting the academic performance, childhood stunting and
of food overall growth failure also increases the risk of developing chronic diseases such as
obesity, impaired glucose tolerance and hypertension during adulthood (Sawaya AL,
2003; Pasricha SR and Biggs BA, 2010). Among female children, menarche is also
Chapter 4 affected by nutritional status and growth patterns during early childhood (Mesa et
al, 2010), and severe stunting is also associated with adverse reproductive outcomes
First Aid and handling (WHO, 1995). Nutritional needs of a preschool child Children under five years of age
emergencies, simply injury, constitute the most vulnerable segment of any community and their nutritional
sprain, burns status is a sensitive indicator of community health and nutrition (Sachdev, 1995).
Good nutrition is necessary to achieve the physiological milestones appropriate for
early childhood. It is often noticed that the children of this age group eat less which
Chapter 5 might be due to the slow rate of overall growth. However, low food intake might
result in failure to meet the nutritional needs which in turn affects their overall
Hygienic care practices growth and development. The nutrient needs for preschool children have been
especially when handling recommended by ICMR (2010) and issued at two levels/age groups of 1-3 & 4-6
children in group situations years. It is important to note that the need for energy and certain nutrients
increases with
ba
UNIT 3
age. Energy Consumption of sufficient energy is very necessary for young children to facilitate body
metabolism, physical activity and thereby their growth and development. Insufficient food /energy intake
is the major reason for body muscle loss and poor growth. Since, overall food intake is a deciding factor of
the energy consumption, ensuring consumption of sufficient food on a daily basis is very essential. Energy
in the diet is contributed simultaneously by carbohydrates, protein and fat which are termed as macro
nutrients. Among these, carbohydrates and fat are valued more for their energy contribution where as
protein is valued for body building.

The issue of Health in the early childhood years is a subject of a volume by itself. In keeping to the context
of this book, we have selected what we think are the most relevant topics, presented below:

1. Growth

2. Vision, Hearing evaluation and its relevance to developmental concerns.

3. Vaccinations

4. Healthy and balanced diet

5. Bladder and bowel control

6. Sleep Hygiene

7. Fall and Head Injury

8. Parental Tips

Chapter 1
Ensuring optimal health and growth measuring head circumference, height, weight,
MUAC, use of growth chart, malnutrition

1.1 What is growth defined as?

Growth is defined as a increase in the number and size of cells and

cd
tissues as measured by anthropological measurements like weight,
height, head circumference, etc. It is determined by both genetic and
environmental factors, nutrition being the most important but not the
only factor among the latter. Growth Monitoring is a screening tool to
1.1 What is growth defined as? diagnose nutritional or chronic diseases at an early stage. It is a
simple yet effective way to identify children who require extra care.
Monitoring the growth of a child requires taking the measurements at
1.2 Assessment of growth regular intervals, and seeing how they change. A single
1.3 MUAC
measurement only indicates the child’s size at that moment. Monitor
Weight, Height and Head Circumference as follows: Age Frequency
of Recording Data Birth to One Year Monthly Second year 2 monthly
1.4 Record of physical Up to 5 years 3 monthly Growth charts are used for ease of growth
growth and monitoring. The normal parameters are already highlighted on this
chart over which a particular child’s measurements are entered and
development 1.5 seen if it is within the normal parameters. It is important and vital to
Vision and Hearing plot the weight and height measurements of a child over a period of
evaluation time and any deviation from the normal pattern should be
investigated at the earliest. An upward curve in the chart indicates
increase and is ideal. If the curve is static or dips down the child
1.6 All about needs immediate
Malnutrition

ba
medical attention. Parents should be involved in growth monitoring
at every step and have to be explained the importance of maintaining and updating the growth
chart of their wards. Body mass index is the body mass (weight in kg) divided by the square of the
height (in metre). The normal range is 18 to 25. A value under 18 indicates under nutrition, 25 - 30
means overweight and above 30 implies obesity. As much as it is important to maintain a BMI
above 18 care takers should also not go overboard as it may lead to obesity and related issues.

1.2 Assessment of growth

Assessment of growth is vital. It provides a sensitive guide to a child’s:

• health

• development
 • nutritional status • response to

treatment.

The measurement of a child’s head circumference is part of this assessment.

Growth measurements encompass the measurement of height, weight and head circumference.
The relationship of all these measurements will identify the need for further monitoring or
investigation (ie a small head circumference with a low weight needs a different approach,
compared to a small head with a normal weight).

An abnormal rate of growth could suggest a pathological disorder requiring diagnosis and possible
treatment (eg hydrocephalus, psychosocial problems, craniosynostosis (Sniderman, 2010).

The aim of measuring a head circumference is to determine the maximal head circumference.

It is performed to:

• Monitor the growth of a child, particularly

those under two years. However, it is still
useful to continue to record a child’s head
circumference, as it may detect any
abnormalities that may develop after this
period (Royal College of Paediatrics and
Child Health (RCPCH), 2013)

• Detect abnormal brain or skull growth (eg

hydrocephalus, craniosynostosis,
microcephaly).

All new born babies should have their head circumference measured. This should not be done
before 36 hours of age. It should be done after 36 hours of age or preferably at 7–10 days
(RCPCH, 2013).

This measurement must be:

• recorded in the child’s health care record

• recorded in the admission assessment

record

• recorded in the child’s parent held record

• plotted on a centile chart.

 1.3 MUAC

Mid-Upper Arm Circumference (MUAC) is the circumference of the left upper arm, measured at
the mid-point between the tip of the shoulder and the tip of the elbow (olecranon process and the
acromium).

MUAC is used for the assessment of nutritional status. It is a good predictor of mortality and in
many studies, MUAC predicted death in children better than any other anthropometric indicator.
This advantage of MUAC was greatest when the period of follow-up was short.

The MUAC measurement requires little equipment and is easy to perform even on the most
debilitated individuals. Although it is important to give workers training in how to take the
measurement, the correct technique can be readily taught to minimally trained health workers and
community-based volunteers. It is thus suited to screening admissions to feeding programs during
emergencies.

MUAC is recommended for use with children between six and fifty-nine months of age and for
assessing acute energy deficiency in adults during famine.

The major determinants of MUAC, arm muscle and sub-cutaneous fat, are both important
determinants of survival in starvation. MUAC is less affected than weight and height based indices
(e.g. WHZ, WHM, BMI) by the localised accumulation of fluid (i.e. bipedal or nutritional oedema,
periorbital oedema, and ascites) common in famine and is a more sensitive index of tissue atrophy
than low body weight. It is also relatively independent of height and body-shape.

1.4 Records of physical growth and development

The monitoring of growth and development serves as a reference for the biological, affective,
psychological and social aspects of a child's health. The monitoring of anthropometric data in
standardized growth curves has become a screening test in the promotion of health, since
individual curves, especially of weight, are sensitive indicators of the health status of children

Weight is the most widely used and simplest, reproducible anthropometric measurements for the
evaluation of nutritional status.

• It indicates body mass

• It is sensitive to even small changes in nutritional status due to childhood morbidity like diarrhea.

• Rapid loss of weight indicates a potential malnutrition

• Serial weight recording is more valuable for progressive growth of a child when age of a child is

not known.
 Technique for measurement
To measure weight beam or lever accentuated scales with an accuracy of 50-100 g are preferred.
Portable Salter scale (CMS Weighing Equipment, Ltd. England): the child is suspended from the
scale which is hung from a branch or a tripod. Special "pants" are used to weigh babies. Robust,
cheap, and easy to carry, these scales should be replaced after one year because of stretching of
the spring and inaccurate readings. The model with readings up to 25 kg (x 100 g) is
recommended. Bathroom scales are not recommended as errors up to 1.5 kgs can occur with this.

Precautions to be taken while weighing

• Zero error has to be adjusted.

• Minimal clothing should be worn and be without shoes.

• While recording the value do not lean against or hold anything.

• Preferably record under basal conditions in early morning.

• Most types of scales (especially beam scales) are sensitive to dust and mud.

Standards

• On an average, a baby weighs double the birth weight by five months, trebles its birth weight by

one year and quadruples its birth weight by two years.

• A baby should gain at least 500g per month in the first three months of life. If the growth is less

than this it points to malnutrition. In different parts of India, the average birth weight is between 2.7

to 2.9 kgs.

• Weight for age is used to classify malnutrition.

Height

• Height of an individual is influenced by genetic as well as environmental factors.

• Maximum growth potential is decided by genetic factors.

• Nutrition and incidences of infection determine the extent of exploitation of that genetic potential.

• Inadequate dietary intake and/ or infections reduce nutrients available at the cellular level.This

results in growth retardation. A prolonged period of severe deprivation leads to stunting.

Technique for measurement

• Children below two years are measured by using an infantometer.

• Baby is made to lie on the scale and crown heel length is measured.
• For children above two years and adults a vertical measuring rod anthropometer- is used and

maximum height is measured.

• Measuring scale should be capable of measuring to an accuracy of 0.1 cm.

Standards

• Length of the baby at birth is 50 cm.

• By first year it increases by 50% to 75cm.

• By third year end it increases by 12cm.

• During puberty, growth spurt, boys add 20cm to their height and girls gain about 16 cm.

• Indian girls reach 98% of their final height by 16.5 yrs. and boys reach the same stage by 17.75
yrs.

• Low height for age indicates nutritional stunting or dwarfing. It reflects past or chronic stunting.

Growth charts are a standard part of any checkup, and they show health care providers how kids
are growing compared with other kids of the same age and gender. They also allow doctors and
nurses to see the pattern of kids' height and weight gain over time, and whether they're
developing proportionately.

Let's say a child was growing along the same pattern until he was 2 years old, then suddenly
started growing at a much slower rate than other kids. That might indicate a health problem.
Doctors could see that by looking at a growth chart.

1.5 Vision and Hearing evaluation

Vision and Hearing Evaluation and its relevance to Developmental Concerns. The care of the well
child and adolescent underlines the importance of preventive pediatrics and evolution of this kind
of health care approach is essential at all stages of a child’s development. The constantly
changing tableau of a child’s development emphasises the need for periodic encounters between
children, their families and the teachers. Developmental disabilities, including those of vision and
hearing, put young children at risk for school failure and school dropout. Such risks, with or
without apparent developmental delay, often result in children being held back in grades,
unemployment and drug abuse. These disabilities are more often than not, preventable at pre
school and school age and if recognised early, prompt therapy can yield miraculous results. The
academician who encounters such a child on a regular basis needs to be sensitised towards these
problems and a prompt referral could save a child’s education. Inattention during classes, falling
grades, frequent absenteeism, apparent lack of concentration or ‘simply does not listen in class’
could be a few red-flag signs of a child who has serious issues with vision or hearing as much as
Attention Deficit Hyperactivity Disorder. Refractive errors, astigmatism, squint, chronic otitis media,
late onset hearing loss are few conditions that are common among school going children although
milder forms of congenital defects may be missed earlier. An annual vision and hearing check up
should be offered to all children. Teachers can be trained and helped by medical professional to
screen children using visual acuity charts. High risk children should be followed up not only by the
medical team but also by the school. Because so much learning is accomplished through the
sense of hearing, screenings are essential to help identify any barriers that would impair a child’s
ability to learn. A pure tone audiometry can be used in children to screen for hearing. Importantly,
before being dismissive of a child’s potential to learn, these developmental disabilities should be
addressed.

1.6 All about malnutrition

Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or
nutrients. The term malnutrition covers 2 broad groups of conditions. One is ‘undernutrition’—
which includes stunting (low height for age), wasting (low weight for height), underweight (low
weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and
minerals). The other is overweight, obesity and diet-related noncommunicable diseases (such as
heart disease, stroke, diabetes and cancer).
Malnutrition affects people in every country. Around 1.9 billion adults worldwide are
overweight, while 462 million are underweight. An estimated 41 million children under the age
of 5 years are overweight or obese, while some 159 million are stunted and 50 million are
wasted. Adding to this burden are the 528 million or 29% of women of reproductive age
around the world affected by anaemia, for which approximately half would be amenable to
iron supplementation. Many families cannot afford or access enough nutritious foods like
fresh fruit and vegetables, legumes, and milk, while foods and drinks high in fat, sugar and
salt are cheaper and more readily available, leading to a rapid rise in the number of children
and adults who are overweight and obese, in poor as well as rich countries. It is quite
common to find undernutrition and overweight within the same community, household or even
individual – it is possible to be both overweight and micronutrient deficient, for example.

In April 2016, the United Nations General Assembly adopted a resolution proclaiming the UN
Decade of Action on Nutrition from 2016 to 2025. The Decade aims to catalyse policy
commitments that result in measurable action to address all forms of malnutrition. The aim is to
ensure all people have access to healthier and more sustainable diets to eradicate all forms of
malnutrition worldwide.
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Kushe, C., Cook. E. and Quamma, J. (1995) Promoting emotional competence in school-aged
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R., Birell Weisen, J. and Orley, J. (1994) Mental Health Programmes in Schools. Geneva: WHO,
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Ltd. - WHO (2003) Documents can be downloaded from the Internet site of the WHO Global
School Health Initiative (www.who.int/school-youth-health)

Chapter 2

Common childhood illnesses, Prevention and Management

(Immunization Schedule)
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2.1 Common Childhood Illnesses, Prevent and management

Chickenpox
21. Common Childhood
Illnesses- Prevention Chickenpox is a common and usually mild childhood illness that
and management can also occur at any stage of life. The illness can be associated
with severe complications and even death so must be treated
seriously in all cases. Immunization can help prevent the spread
2.2 Immunization
of chickenpox. Chickenpox causes a rash of red, itchy spots that
Schedule turn into fluid-filled blisters. They then crust over to form scabs,
 ba which eventually drop off. The child is likely to have a fever at
least for the first few days of the illness and the spots can be
incredibly itchy, so expect them to feel pretty miserable and
irritable while they have chickenpox.

Some children have only a few spots, but in others they can cover the entire body. The spots are
most likely to appear on the face, ears and scalp, under the arms, on the chest and belly and on
the arms and legs. The incubation period for chickenpox is between 10 and 21 days. You are
infectious from up to 2 days before the red spots appear and until around 5 days after all scabs or
crusts are dry.

Chickenpox can be severe at any age and have serious complications. Complications include:

• bacterial skin infections

• pneumonia
• swelling of the membranes covering the brain (aseptic meningitis)
• decrease in blood platelet cell (thrombocytopenia)
• bleeding problems
• infection of the blood (sepsis)
• inflammation or infection of the brain (encephalitis)
• trouble with balance and co-ordination (cerebellar ataxia)
• foetal abnormalities in pregnant women (see below)
• dehydration

Pregnant women should be especially careful to avoid chickenpox as it can affect the unborn baby
by causing foetal malformations, skin scarring and other serious problems (congenital varicella
syndrome).

There is no specific treatment for chickenpox, but there are medicines and pharmacy products
which can help alleviate symptoms, such as:
• paracetamol to relieve fever
• calamine lotion and cooling gels to ease itching

In most children, the blisters crust up and fall off naturally within one to two weeks.

Adults who have had chickenpox as a child may also get shingles later in life, as they are both
caused by the virus varicella zoster.
Coughs

In children cough is a common symptom which is commonly caused by a cold. Usually a cough
gets better on its own and is not serious. If your child is feeding, drinking, eating and breathing
normally and there’s no wheezing, a cough isn’t usually anything to worry about.

. Causes of a more serious cough in children can include:

• croup
• whooping cough
• asthma
• pneumonia
• swallowing a foreign object e.g. peanut

Signs of a more serious cause of a childhood cough can include:

• high temperature
• persistent (longer than 2 weeks) or an unusual cough
• difficulty breathing
• the cough occurs at night
• the child is listless, overly tired or in discomfort
• your child's skin changes colour and turns blue or very pale

Sore throats

The most common cause of a sore throat is a viral illness, such as a cold or the flu. Your
child’s throat may be dry and sore for a day or two before a cold starts. Infant or child dosage
paracetamol or ibuprofen can be given to reduce the pain.

Most sore throats clear up on their own after a few days.

Colds

It is normal for a preschool child to have at least 6 or more colds a year. This is because there are
hundreds of different cold viruses and young children have no immunity to any of them as they've
never had them before. Gradually they build up immunity and get fewer colds.
Antibiotics don’t help with colds as they are a viral illness. Most colds get better in 5 to 7 days.
Here are some suggestions on how to ease the symptoms in your child:

• Increase the amount of fluid the child normally drinks.

• Saline nose drops can help loosen dried nasal secretions and relieve a stuffy nose.
• If the child has a fever, pain or discomfort, paracetamol or ibuprofen can help. There are
child and infant products that will state on the packet how much you should give children of
different ages.
 • Encourage the whole family to wash their hands regularly to stop the cold spreading.

Ear infections

Ear infections are common in babies and small children. They often follow a cold and sometimes
cause a temperature. A child may pull or rub at an ear, but babies can’t always tell where pain is
coming from and may just cry and seem uncomfortable.

. Don’t put any oil, eardrops or cotton buds into the child’s ear unless the doctor advises to do so.
Most ear infections are caused by viruses, which can’t be treated with antibiotics. They will just get
better by themselves.

Glue ear

Repeated middle ear infections (otitis media) may lead to 'glue ear' (otitis media with effusion),
where sticky fluid builds up and can affect your child’s hearing. This may lead to unclear speech
or behavioural problems.

Diarrhoea and vomiting may be caused by many different things, including:

• a virus
• a stomach bug
• food poisoning
• eating something you may have an allergy to.

Fever

A fever is a temperature of 38°C or higher. Fever is one of the ways the body fights infection.It can
develop slowly, over a few days, or the fever can rise very quickly. Usually, this doesn't have
anything to do with the illness that causes the fever. If the child's face feels hot to the touch and
they look red or flushed, then they may have a fever. You can check their temperature with a
thermometer.

A normal temperature in children is 36.5°C to 37.5°C although it depends on the person, their age,
what they have been doing, the time of day and at which part of the body you take the
temperature.
Body temperature is usually lowest in the early hours of the morning and highest in the late
afternoon and early evening.

Infections are by far the most common cause of fever in children. Most of these are caused by
viruses, which are responsible for colds, upper respiratory infections, and the common infectious
diseases of childhood. These infections don't last long and usually don't need to be treated. Some
infections are caused by bacteria and need treatment with antibiotics. These include certain ear
and throat infections, urinary tract infections, pneumonia and blood infections. You need to see a
doctor if you think your child has any of these infections.

There are other, relatively uncommon, causes of fever. These include allergic reactions to drugs or
vaccines, chronic joint inflammation, some tumours and gastrointestinal diseases. Febrile
convulsions are seizures that happen because of a fever. They occur in about 4% of children
between the ages of 6 months and 5 years. Children outgrow febrile convulsions by the age of 4
to 5 years. Febrile convulsions have no long-term consequences, but you should talk to your
doctor about them.

Measles

Measles is a highly infectious disease caused by a virus that is spread from person to person
through droplets in the air. It can be very unpleasant and often leads to serious
complications .Anyone can get measles if they haven’t had the disease before, although it’s much
more common in those who have not been vaccinated. Measles is a vaccine preventable disease
and vaccination against the disease is recommended as part of routine childhood
immunisation.Early symptoms of measles include fever, cough, feeling tired, a sore throat, runny
nose, discomfort looking at light and sore, watery eyes. A rash appears after the third or fourth day.
The spots are red and slightly raised. Measles rash looks like red, slightly raised spots and
may be blotchy but not itchy.

Someone with measles is infectious for 24 hours before the rash appears, and four days
afterwards. The illness usually lasts about 10 days. Anyone who suspects they might have
measles should stay home and should not attend school, child care or work.

The best way for you to protect yourself and others is to get vaccinated. Measles is caused by a
type of virus called a paramyxovirus. This kind of virus spreads from person to person via
‘droplets’ from coughing or sneezing. Measles is so contagious that about 9 in 10 people who
come in contact with the virus will catch it if they are not immunised.

You can catch measles by breathing in these droplets or, if the droplets have settled on a surface,
by touching the surface and then placing your hands near your nose or mouth. The measles virus
can survive on surfaces for a few hours.

Once inside your body, the virus multiplies in the back of your throat and lungs before spreading
throughout your body, including your respiratory system and the skin.

Mumps
Mumps is a contagious viral infection that is most common in children between 5 and 15 years of
age. These days it’s rarely seen because of effective immunisation. Mumps is most recognisable
by the painful swellings located at the side of the face under the ears (the parotid glands), giving a
person with mumps a distinctive 'hamster face' appearance. Other symptoms
include headache, joint pain and a high temperature.

Mumps is caused by the mumps virus, which belongs to a family of viruses known as
'paramyxoviruses'. It's spread by close contact or by coughing and sneezing. Paramyxoviruses are
a common source of infection, particularly in children. When you get mumps, the virus moves from
your respiratory tract (your nose, mouth and throat) into your parotid glands (the glands that
produce saliva), where it begins to reproduce. This causes inflammation and swelling of the
glands. The virus can less commonly also enter your cerebrospinal fluid (CSF), which is the fluid
that surrounds and protects your brain and spine. Once the virus has entered the CSF, it can
spread to other parts of your body, such as your brain, pancreas, testes (in boys and men) and
ovaries (in girls and women). Whooping Cough

Whooping cough (also known as 'pertussis') is a highly infectious infection of the lungs and
airways. It is caused by a bacteria. The disease is most serious in babies under the age of 12
months, particularly in the first few months. Young babies are most at risk of harm from whooping
cough as they have soft airways that can be damaged from the severe coughing bouts. They may
not yet have had their whooping cough vaccinations, which make the disease less severe.

Older children and adults, including those who have been vaccinated, can still get whooping
cough.
While it is not as critically dangerous as it is in small babies, it is still a distressing condition, with
the cough lasting up to 3 months. Whooping cough has been called the ‘100 day cough’. The
condition usually begins with a lasting dry and irritating cough that progresses to intense bouts of
coughing. Particularly in small children, these bouts can be followed by a distinctive 'whooping'
noise as the child breathes in, which is how the condition gets its name, but in many cases the
only sign is the hacking cough.

Other symptoms include a runny nose, raised temperature and vomiting after coughing.Symptoms
appear about 7 to 10 days after you are infected. You are infectious from the first signs of the
illness until about 3 weeks after coughing starts. If an antibiotic is given, the infectious period will
continue for up to 5 days after starting treatment.

It is now recommended that all pregnant women receive a pertussis (whooping cough)
vaccination during their third trimester (ideally at 28 weeks). A combination of antibodies being
passed through the mother’s bloodstream and the reduced risk of the mother contracting the
disease makes this an ideal time to administer the vaccine.

Fathers, grandparents and anyone else who is likely to come into contact with newborns should
see their doctor to get a pertussis booster at least 2 weeks before the baby is born.
Rubella

Rubella (also known as 'German measles') is a viral infection that used to be common in children.
It is usually a mild infection. Symptoms of rubella include a distinctive red-pink skin rash, swollen
glands (nodes), and cold-like symptoms such as a mild fever, sore head and runny nose. Rubella's
incubation period is between 2 and 3 weeks with its infectious period lasting from 1 week before
the rash first appears until at least 4 days after it's gone. It's recommended children are immunised
against rubella as part of their routine childhood immunisation program.

Rubella is caused by the rubella virus that's spread through personal contact, or by coughing and
sneezing. Once you have had rubella then you normally develop a lifelong immunity against
further infection. Rubella is best prevented by the MMR vaccination.

If a pregnant woman who does not have immunity to rubella (either due to previous infection or
vaccination) catches the rubella virus, then the virus can be passed on to her unborn baby. The
virus can disrupt the development of the baby, causing a series of birth defects that are known as
congenital rubella syndrome (CRS). The risk of CRS affecting the baby and the extent of the birth
defects it causes depends on how early in the pregnancy the mother is infected. The earlier in the
pregnancy the greater the risks. CRS can include hearing and visual impairments, developmental
delay and other problems in the baby. As many as 9 out of 10 babies whose mother caught rubella
during the first 10 weeks of pregnancy will have CRS, with multiple birth defects. After 20 weeks
there is no risk of the baby developing CRS.

2.2 Immunization Schedule

Vaccination As the age old saying goes, 'prevention is better than cure". Vaccines are biological
preparations that improve immunity to a particular disease. The schedule to be followed for vaccinating a
child is: BCG At birth DPT 6 weeks, 10 weeks, 14 weeks and a booster at 1.5 years of age DT 5 years TT 10
years OPV Birth, 6 weeks, 10 weeks, 14 weeks and two boosters at 1.5 years and 5 years Measles 9 months
MMR 15 months Hepatitis B At birth, 1 month and 6 months; Booster every 10 years. Care takers should
ensure that each and every child has been immunised for age and a record should be maintained in the
school. In case the child has not been vaccinated, facilities for catch up vaccination should be made
available. Also all children below 5 years of age should be encouraged to receive pulse polio drops. The
above mentioned vaccines are provided free of cost by the Government of India. 200 Optional vaccines
that can be offered to parents include pneumococcal, influenza, typhoid, chicken pox , Hepatitis A and
Human Papilloma Virus vaccine.

Bibliography:

NHS Choices (UK) (Treating a high temperature in children), Sydney Children Hospitals
Network(Fever) National Health and Medical Research Council (Staying Healthy -
Preventing infectious diseases in early childhood education and care services - 5th Edition,
updated June
2013), NHS Choices(Diarrhoea and vomiting in babies and children), The Gut
Foundation (Diarrhoea in children),Royal Children's Hospital Melbourne (Gastroenteritis (Gastro))
Raising Children Network (Colds), The Royal Children's Hospital Melbourne (Viral
illnesses),Raising Children Network (Coughs), Raising Children (Middle ear infection), Raising
Children Network (Sore throats), The Royal Children's Hospital Melbourne (Ear infections and glue
ear) NPS Medicinewise (Chickenpox vaccine), Australian Department of Health (Immunise
Australia
Program), Healthy WA (Chickenpox (varicella)) Australian Government Department of
Health (Measles), SA Health (Measles - including symptoms, treatment and prevention),
NHS
Choices (Measles) NHS Choices (Causes of mumps), Raising Children Network (Mumps), NHS
Choices (Mumps, Introduction) NHS Choices (Rubella), Australian Department of Health
(Immunise Australia Program), SA health(Rubella (German measles) - including symptoms,
treatment and prevention))
 Chapter 3

Nutrition importance of BF, Complementary feeding,

• Food of groups and balanced meal planning,

cd
3.1 All about Nutrition
• Safe handling of food
3.2 Importance of
Breast Feeding
3.1 All about Nutrition and balanced meal planning
3.3 Complementary
Feeding Early childhood (2 to 6 years) is one of the crucial periods of life
characterized by substantial physical and psychological changes.
Although the rate of growth slows down during this period compared to
ba infancy, the child continues to gain weight and height. The weight of the
child quadruples and height grows by two thirds. Moreover, a
remarkable growth of brain occurs during early childhood reaching
90% of adult size (Tanner, 1978). Good nutrition is very essential to facilitate normal growth and
development of the children in this age group. However, under nourishment has been reported to
be a very serious problem contributing to growth failure among preschoolers in India, in spite of
considerable economic development and improved food production. This might be due to low
quality of complementary foods fed to the child from infancy onwards, high burden of intestinal
parasitic and other infections, poor socioeconomic back ground, low birth weight (LBW) and
intrauterine growth retardation etc. (Kuklina EV et al, 2006). Diarrhoea, respiratory diseases and
infections such as measles are common health problems due to malnutrition in this age group
which further affect their nutritional status. Failure to achieve the genetically potential height is one
of the repercussions of malnutrition resulting in stunting. Research has proved that impaired food
intake during early stages of life not only affects the immediate growth and development but might
even affect their growth in later periods of life i.e. childhood and adolescence. In addition to
adversely affecting the academic performance, childhood stunting and overall growth failure also
increases the risk of developing chronic diseases such as obesity, impaired glucose tolerance and
hypertension during adulthood (Sawaya AL, 2003; Pasricha SR and Biggs BA, 2010).

Among female children, menarche is also affected by nutritional status and growth patterns during
early childhood (Mesa et al, 2010), and severe stunting is also associated with adverse
reproductive outcomes (WHO, 1995). Nutritional needs of a preschool child Children under five
years of age constitute the most vulnerable segment of any community and their nutritional status
is a sensitive indicator of community health and 212 nutrition (Sachdev, 1995).

Good nutrition is necessary to achieve the physiological milestones appropriate for early
childhood. It is often noticed that the children of this age group eat less which might be due to the
slow rate of overall growth. However, low food intake might result in failure to meet the nutritional
needs which in turn affects their overall growth and development. The nutrient needs for preschool
children have been recommended by ICMR (2010) and issued at two levels/age groups of 1-3 & 4-
6 years (Table1). It is important to note that the need for energy and certain nutrients increases
with age. Energy Consumption of sufficient energy is very necessary for young children to facilitate
body metabolism, physical activity and thereby their growth and development. Insufficient food
/energy intake is the major reason for body muscle loss and poor growth. Since, overall food
intake is a deciding factor of the energy consumption, ensuring consumption of sufficient food on a
daily basis is very essential. Energy in the diet is contributed simultaneously by carbohydrates,
protein and fat which are termed as macro nutrients. Among these, carbohydrates and fat are
valued more for their energy contribution where as protein is valued for body building.

Carbohydrates Cereals, legumes, roots and tubers provide carbohydrate in the usual diet. Quality
of carbohydrate should be given due importance in the diet even for this age group in the light of
increasing incidence of childhood obesity and other chronic diseases in later years especially in
Indian population. Starchy foods such as pasta, bread and rice could be included in the diet in the
required amounts. But, sugar content in the diet needs to be 213 restricted as strong links have
been reported between sugar intake, hyperactivity and dental caries. Moreover, frequent
consumption of sugary drinks and sweets should be discouraged as these influence the child's
appetite and decrease consumption of healthy food in the later meals. Sweets are better
consumed after a meal rather than between meals. Teeth should be cleaned twice daily after
breakfast and before bedtime. It is also advisable to visit dentist at least once a year to ensure
good dental health. As the child grows, consumption of dietary fiber should be encouraged as the
child grows. It facilitates good bowel movements and support growth of friendly gut bacteria by
acting as a prebiotic (a component that facilitates growth of friendly probiotic bacteria in the gut).
The sources of dietary fiber include whole wheat bread, whole meal breakfast cereals, pulses,
fruits and vegetables etc. It is necessary to inculcate the habit of eating these foods on a daily
basis in this age group as it would be difficult to do so in the later years. Consumption of these
foods offer several other health benefits such as controlling unnecessary weight gain, contributing
certain B complex vitamins and minerals.

However, inclusion of excessive amount of fiber is harmful to the body as it impairs absorption of
certain essential minerals such as iron, zinc and calcium (Clarke B, Cockburn F, 1988) besides
inducing diarrhoea and affecting overall food intake by making the meal bulky. Hence, fiber should
be included in small quantities each time. A daily consumption of around 20grams of dietary fiber
including soluble and insoluble fiber is sufficient for this age group. Protein Protein is also called
body building nutrient as its requirement is mainly for synthesis of various tissues in the body
including muscle, bones and other tissues. Besides, proteins are also important for synthesis of
enzymes required for metabolism. The body's immunity depends on the protein nutritional status.
Proteins are basically made up of several amino acids among them 9 are not synthesized in the
human body and hence needs to be supplied through diet everyday. These are called essential
amino acids (EAA). A good quality protein (Protein from non vegetarian sources) contains all these
essential amino acids where as protein in vegetarian foods lacks in one or more of these. Hence
vegetarian proteins are called incomplete proteins. But protein from soybeans is an exception as
its composition is very close to that of nonvegetarian protein. Thus selection of good sources of
protein is crucial. Human body utilizes good quality protein from non vegetarian foods such as
meat, dairy products, eggs, chicken and fish more efficiently. While providing protein, these foods
also contribute good quality calcium which is an additional advantage. Hence provision of around
70% of protein through non vegetarian sources would be ideal. Since soybeans or soy products
offer the best quality protein 214 among vegetarian sources, it offers a better choice to
vegetarians. Since protein deficiency is one of the major nutritional problems especially among
young children that affect their overall growth and development, meeting protein needs on a daily
basis is very important to avoid stunting.

Fat is a dense source of energy providing twice the amount (9 Kcal/g) of energy as compared to
carbohydrates and protein (4 Kcal/g each). Around 25 -30% of total energy can be provided to the
children daily in the form of fat. Besides providing energy, it facilitates absorption of fat soluble
vitamins too. The type of oil to be used in cookery has always been a topic of interest to mothers.
The decision on selection of cooking oil depends largely on its fatty acid composition. Dietary fat is
composed of three types of fatty acids-saturated, mono and poly unsaturated fatty acids. All these
need to be supplied to the body in the ratio of 1:1.5:1.
There should be no over emphasis of unsaturated fatty acids in the diet which is observed
regularly now a days. Saturated fat which is present in butter, ghee, whole milk and milk products
also offers certain health benefits such as synthesis of HDL (Good) cholesterol, facilitating
neuronal growth etc., to the body besides providing energy and hence should be included in the
diet as per the recommendations. Ensuring daily consumption of unsaturated fatty acids especially
the omega 3 fatty acid is very essential as these are required for the growth and functioning of
central nervous system and immunity. Fish, soya bean, rice bran and canola oils are good sources
of omega 3 fatty acids. It is necessary to educate parents particularly that low fat milks and foods
are not suitable for young children. Minerals Iron is a constituent of hemoglobin and hence low iron
intake leads to anemia. As the child grows, the blood volume and thereby the hemoglobin content
in the blood increase, which increase the demand for iron. Hence, the iron requirement increases
with age from 1-6 years. Moreover, iron is also required for cognitive performance of the child and
hence the academic performance of anemic children has been reported to be poor. Iron rich foods
such as red meat, liver, fortified cereals and green leafy vegetables should be regularly included in
the diet. The body's ability to absorb iron depends on the type of iron consumed i.e. Haem or non
haem iron.

Non vegetarian foods provide 'Haem' iron which is more bioavailable than the 'Non-Haem iron' in
vegetarian foods (Breakfast cereals with added iron, Dark green vegetables, Whole meal bread,
Dried fruit: raisins, apricots, prunes, Baked beans, beans, lentils, split peas etc.). But, consumption
of vitamin 215 C from any fruit juice and/or protein from meat, chicken and fish along with sources
of iron improves absorption of non-haem iron. Calcium is vital for bones and teeth. Consumption of
2-2 1/2 cups of dairy foods (milk and milk products) would ensure calcium need of the growing
child. But absorption of dietary calcium depends on vitamin D status of the child. Exposure to
adequate sunlight is necessary for the synthesis of vitamin D in the body. Playing outside before
11am or after 4pm for 10-15 minutes, 2-3 times a week (without a hat or sunscreen and arms or
legs uncovered) is sufficient to ensure adequate synthesis of Vitamin D. In addition to iron and
calcium, zinc and iodine are also important for the Immunity, overall growth and development.
Water -cereals & legumes -Roots & tubers Vitamins Human body requires two types of vitamins-
fat soluble (vitamins A, D, E, & k) and water soluble (B-complex & C). Preschool age is very
sensitive to deficiencies of vitamin A which leads to night blindness and/or disturbance to the
overall structure and functioning of the eye besides affecting immunity. Vitamin D is required for
the absorption of calcium and thereby for bone health. Among the water soluble vitamins, thiamin,
riboflavin, niacin and pyridoxine are needed for the utilization of macronutrients in the body. Folic
acid and Vitamin B-12 are required for the RBC synthesis and maturation, and thereby their
deficiency leads to megaloblastic anemia. and vitamin C is 216 required for wound healing,
healthy gums and immunity. Since the sources of vitamins are widely varied, consumption of
variety of foods i.e. foods from each of the food group is necessary to meet the requirements.

The 'My Plate' concept issued by USDA is very useful for young children to select variety of foods.
Consumption of wholegrain (cereals and legumes), 1- 1 1/2 cups of vegetables, 2- 2 1/2 cups of
fruits ( different varieties) would ensure meeting the requirements of beta carotene (precursor of
vitamin A), vitamin C and B complex vitamins. Water The major constituent in human body is
water. Everyday certain amount (around 2 liters in an adult) of water is used by the body to excrete
the metabolic wastes which needs to be replaced to maintain the physiological homeostasis in the
body and to avoid dehydration. Unfortunately, in the recent times, soft drinks have almost replaced
water in our diet especially in the younger generation including toddlers. The sugar present in
these drinks contributes to dental caries, weight gain and obesity. Hence, it is very important to
inculcate habit of regular water consumption among children from early stages of life. Such a
practice would prevent dehydration while facilitating excretion of body wastes. Set good Dietary
practices Early childhood is also a crucial period for formulation of good eating habits. Picky eating
behavior is often reported in this age group. The responsibility of not only providing nutritious food
but inculcating good food habits to children lies with family members and other care givers. The
nutritional needs of preschoolers can be met by offering foods from all the food groups. Based on
recommendations of Indian Council of Medical Research the following foods should be included in
the preschoolers’ diet every day: 5-6 servings of cereals ( roti, whole wheat bread rice, pasta,
noodles etc.) 2-3 servings of milk and milk products like ( plain (sweetened/unsweetened) milk,
milk shake, yoghurt, paneer, cheese etc.) 1 small portion of meats like chicken, fish, eggs and 1
portion of pulses like lentils, chickpeas, green gram etc. 3-4 portions of fruits and vegetables The
amount of food a preschooler chooses to eat will vary according to their size and activity levels.

But parents /care givers should choose foods from the core food groups and prepare recipes
suitable to be packed in the Tiffin box as mentioned below.Foods 217 For the 'Tiffin box': Breads
or cereal based foods like sandwiches, parantha rolls with veggies, sprouts, whole wheat bread
with a veggie or egg filling, rolled up, pasta or rice based salad, crackers with a spread, fruit-based
muffins Include a dairy food for lunch or breakfast (eg a cheese sandwich, yogurt, custard) Firm
fresh fruits, as well as dried fruits, are easy to send for morning tea or lunch Choose easy-to-eat
vegetables such as cucumber sticks, celery, carrot sticks and capsicum. Remember to cut them
appropriately for small fingers Handy finger foods like cutlets, hard boiled eggs, small
sandwiches, rolls, whole fruits are easy to pick up and at school The "Fast Food" scenario: Very
often converting theory into practice becomes difficult especially when the external influences are
very strong resulting in the picky eating behavior of the kids. One type of food has been causing
great concern in the minds of parents as well as health care specialists i.e. 'Fast Food'. Fast food
is food that can be prepared quickly and not necessarily rich in oil/fat. The most commonly known
fast foods include burgers, samosas, hot dogs, pizzas, kebabs, sandwiches, cutlets and pakodas.
The concern related to fast food is mainly the trans fat content in food purchased outside . Hence,
selecting healthy fast food options from commercial outlets and/or preparing fast foods at home
are the two good options to the parents. Healthy Fast Food Options Mixed salad with lots of
vegetables, fruits with low fat yoghurt dressing or boiled eggs Bhelpuri is a healthy Indian snack
that you can consider when hunger strikes. It consists of puffed rice, sliced onions, potatoes and
sauces. Add peanuts, pomegranates, grated carrot and diced cucumber to give it a healthy touch.
Dahiwada (bite-sized cutlets immersed in yoghurt) is another healthy snack. Vegetable baked
dishes Wholegrain pasta, brown rice or dishes with low-fat sauces Soups and stews. Opt for
Soups which are prepared using fresh vegetables. Homemade kebabs and cutlets fried in olive oil
with plenty of fresh vegetables, multigrain bread, low-fat meat such as chicken or fish fingers or
low-fat homemade paneer (cottage cheese).

. Provision of sufficient energy to the children through carbohydrate rich foods/meals/recipes prior
to the sports activities is very important to avoid problems on the field. Food should be easily
digestible while easy to carry in their school bags. Along with food, consumption of water through
sports drinks/juices/milkshake or fruit smoothies should also be facilitated and insisted in order to
avoid dehydration. Food and eating is a learning experience for children which they acquire from
elders (especially parents and older siblings) in the family. Preschoolers have an established daily
routine and need regular mealtimes to be part of this. Parents and preschools should provide
suitable foods at mealtimes, including morning and afternoon tea. It is up to the child to eat from
what is offered. Food should be attractively presented and should be in bite sizes so that the child
can just pick up a bite and put it in their mouth. Unless the food is colourful and attractive, the child
would not be interested in trying out the food and would be more interested in continuing his play.
After a day at preschool and possibly attending activities in the afternoon, some children will not
be hungry at dinner time. They may have eaten enough during the day at earlier meals. So make
the mealtime a pleasant social time together. It is an opportunity for parents to show their children
appropriate eating behaviours, including eating a variety of foods, tasting new foods, even if the
preschooler is not actually eating. Mealtimes should be a family and social occasion. To
encourage this, distractions such as television should be avoided while eating. Following are some
of the measures to inculcate good dietary practices among young children. Encourage children to
sit at the table when they eat, and give them plenty of time to eat their meal. Even if you are not
eating with your children, sit at the table with them. Young children should be supervised while
they eat, to aid in encouragement and in case of choking. Don't use food as a reward or as a
punishment. This can lead to unhealthy attitudes toward eating and food. Respect your children's
food preferences, and let them choose or reject foods as adults or older children do. Get your
children involved in preparing certain parts of the meal. Make every effort to make eating, and not
watching television, the main focus of the family meal. Use child-size dishes and utensils that the
child can handle with ease. Using too large a plate can be overwhelming. Offer foods with kid
appeal. Younger children usually like plain, unmixed foods, as well as finger-foods that make
eating easier. 220 Offer plenty of variety from each of the food groups. If your children don't like
spinach, don't assume they don't like vegetables. Just offer another vegetable. Good nutrition
during early childhood facilitates optimum growth and development while preventing future health
problems. Among the various factors influencing nutritional status of preschool children, literacy of
parents and personal hygiene have also been reported to play an important role (Meshram et al,
2012). Growth failure which often results from poor nutritional status is also a predictor of poor
survival and development of adult human capital in the survivors (Black et al., 2008). Hence, it is
very essential to safeguard the vulnerable younger generation from malnutrition.

3.2 Importance of Breast Feeding

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and
development of infants; it is also an integral part of the reproductive process with important
implications for the health of mothers. Review of evidence has shown that, on a population
basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants. Thereafter
infants should receive complementary foods with continued breastfeeding up to 2 years of age
or beyond. Breast milk is the natural first food for babies, it provides all the energy and
nutrients that the infant needs for the first months of life, and it continues to provide up to half
or more of a child’s nutritional needs during the second half of the first year, and up to one-
third during the second year of life.
Breast milk promotes sensory and cognitive development, and protects the infant against
infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to
common childhood illnesses such as diarrhoea or pneumonia, and helps for a quicker
recovery during illness.
Breastfeeding contributes to the health and well-being of mothers; it helps to space children,
reduces the risk of ovarian cancer and breast cancer, increases family and national resources,
is a secure way of feeding and is safe for the environment.

3.3 Complementary Feeding

When breast milk is no longer enough to meet the nutritional needs of the infant,
complementary foods should be added to the diet of the child. The transition from exclusive
breastfeeding to family foods, referred to as complementary feeding, typically covers the
period from 6 to 18-24 months of age, and is a very vulnerable period. It is the time when
malnutrition starts in many infants, contributing significantly to the high prevalence of
malnutrition in children under five years of age world-wide.

Complementary feeding should be timely, meaning that all infants should start receiving foods
in addition to breast milk from 6 months onwards. It should be adequate, meaning that the
complementary foods should be given in amounts, frequency, consistency and using a variety
of foods to cover the nutritional needs of the growing child while maintaining breastfeeding.
Foods should be prepared and given in a safe manner, meaning that measures are taken to
minimize the risk of contamination with pathogens. And they should be given in a way that is
appropriate, meaning that foods are of appropriate texture for the age of the child and
applying responsive feeding following the principles of psycho-social care.
The adequacy of complementary feeding (adequacy in short for timely, adequate, safe and
appropriate) not only depends on the availability of a variety of foods in the household, but
also on the feeding practices of caregivers. Feeding young infants requires active care and
stimulation, where the caregiver is responsive to the child clues for hunger and also
encourages the child to eat. This is also referred to as active or responsive feeding.
World Health Organization recommends that infants start receiving complementary foods at 6
months of age in addition to breast milk, initially 2-3 times a day between 6-8 months,
increasing to 3-4 times daily between 9-11 months and 12-24 months with additional nutritious
snacks offered 1-2 times per day, as desired.

3.4 Safe handling of food

Safe steps in food handling, cooking, and storage are essential to prevent food borne illness. You
can't see, smell, or taste harmful bacteria that may cause illness. In every step of food
preparation, follow the four steps of the Food Safe Families campaign to keep food safe:

• Clean — Wash hands and surfaces often.

• Separate — Don't cross-contaminate.
• Cook — Cook to the right temperature.
• Chill — Refrigerate promptly.

Preparation
 • Always wash hands with warm water and soap for 20 seconds before and after handling
food.
• Don't cross-contaminate. Keep raw meat, poultry, fish, and their juices away from other
food. After cutting raw meats, wash cutting board, utensils, and countertops with hot, soapy
water.
• Cutting boards, utensils, and countertops can be sanitized by using a solution of 1
tablespoon of unscented, liquid chlorine bleach in 1 gallon of water.

• Refrigerator: The refrigerator allows slow, safe thawing. Make sure thawing meat and
poultry juices do not drip onto other food.
• Cold Water: For faster thawing, place food in a leak-proof plastic bag. Submerge in cold
tap water.
Change the water every 30 minutes. Cook immediately after thawing.
• Microwave: Cook meat and poultry immediately after microwave thawing.

General safe food handling tips:

• Do not wipe your hands on your clothing as this can easily transfer microbes and bacteria.
• Use paper towels to clean up during food preparation and serving.
• Change gloves, utensils and dishes when changing functions. For instance use one pair of
gloves for handling raw meat, and another pair handling fresh vegetables.
• Never run in food production or service areas
• Try to have just one person serve food that is about to be eaten.
• Prepare precooked frozen foods exactly as the directions/instructions on the packaging
state.
• Have foods ready not any longer than necessary before serving time.
• Prepare and cook only as much food as you intend to use.
• Wash and sanitize flatware or other utensils, which fall to the floor.
• Do not taste foods with any utensil used either to mix or stir food.
• Pick up and hold all tableware by the handles.
• Store tableware away from dust.
• Be careful when lifting lids from hot food.
• Turn handles of saucepans away from the front of the stove when cooking.

Picking up ready to eat food

Whenever possible always try to handle any food items that are about to be eaten, with a utensil
(i.e. tongs) rather than your bare hands.

Hand washing
Clean hands are essential for working in a kitchen environment. It’s very easy for bacteria to
spread from the food we touch to door handles, plates, cutlery and so on. Hand washing is one of
the best ways to prevent the spread of germs between people.

When washing your hands try to;

• Use a soap dispenser rather than a bar of soap.

 • Wash in a sink that has hot and cold running water.
• Wash in a sink that is separate from one that is used to wash foodstuff and utensils.
• Dry your hands with paper towels.

Wash your hands after:

• Starting work
• Using the toilet
• Handling raw and cooked foods
• Taking breaks
• Eating
• Drinking
• Smoking
• Coughing, sneezing or blowing their nose
• Touching your hair
• Playing with pets or handling animals
• Scratching
• Handling refuse or waste materials
• Handling cleaning chemicals

Procedure to washing your hands properly

• Wet your hands

• Rub your hands and wrists with soap
• Lather the soap for 20 seconds
• Rinse thoroughly
• Dry with paper towels or a hot air dryer (remember that wet hands can carry and transfer
more germs than dry ones)
• Turn of the taps with your elbows (if possible) or use a paper towel to do so.

Hand basins and sinks

The sink you wash your hands in should be separate from ones where you prepare food or
washing dishes. It should be in an accessible place, as this encourage people to use it and make
it more likely to be used.

Gloves
Gloves are ideal for helping you to minimize bare hand contact with any cooked and ready-to-eat
foods. They are there to protect both the food and the worker (i.e. they can be used to cover
damaged skin or protect hands from risk of developing skin conditions).

Gloves must not be regarded as a “second skin”. They can become contaminated with bacteria in
exactly the same way that hands can. They are not a substitute for good personal hygiene and
hand washing.

• Replace gloves after each task.

• Wash and dry hands thoroughly before putting on any gloves
• Always use single use fresh gloves.
 • Throw away plastic gloves after one use.
• The improper use of gloves can increase rather than reduce food hygiene risks, for
instance a punctured glove can lead to glove material ending up in food.
• Gloves must only be used for one particular task.
Change gloves:

• At least once every hour.

• If they become contaminated.
• If they tear.
• When switching between handling raw and ready-to-eat foods.
• When changing tasks.
• After mopping, taking rubbish out, sweeping and cleaning.

Handling dishes, crockery and cutlery

• Try not to touch any part of a dish or plate which will come into contact with a person’s food
or mouth.
• Pick up cups and mugs by their handles, your fingers should be outside cups.
• Place teaspoons so they protrude from a dish.
• Pull out disposable cups from the base of a tube, this prevents your fingers from going
inside the cup.
• Do not use plates which have become cracked or chipped.

Clothes
Try to avoid wearing outdoor clothes in a food preparation area, instead wear clean, and where
appropriate, washable protective clothing.

Wear:

• A clean apron
• Gloves
• Hairnet
• Closed-in shoes to protect your feet, in case of hot spills or breakages.
• Shoes with slip-resistant soles, to stop you from slipping on hot spillages, etc.

Do not:

• Use your apron to wipe your hands on.

• Cook in loose fitting clothes.
• Work in the kitchen in soiled clothing.

Personal hygiene
Food service workers must maintain a high degree of personal cleanliness when receiving,
storing, cooking, processing, packaging, transporting or disposing of food.
Here are some basic tips to follow;

• Keep fingers away from your face, mouth, hair, skin and other parts of the body.
 • Don’t brush or comb your hair when you are near food.
• Wash your hands frequently.
• Never smoke in food areas.
• Do not handle food with bare hands – use gloves instead.
• Do not eat or chew gum in food handling areas.
• Don’t cough, sneeze, spit or smoke near food and avoid touching your nose, teeth, ears
and hair, or scratching when handling food.
• Do not use fingers to sample food. Always use a clean spoon.

Using knives
Always handle knives and other sharp equipment with care. Accidents involving knives are
common in the catering industry, and usually involve cuts to a person non-knife hand and fingers.
When using a knife always:

• Cut away from yourself or downwards on a chopping board to avoid cutting yourself.
• Cut on a stable surface.
• Keep knives clean, sanitised and grease free, all of these will help you have a firmer grip.

Tips:

• Use a knife suitable for the task and for the food you are cutting.
• Keep knives sharp.
• Carry a knife with the blade pointing downwards.

Using a knife
When using a knife remember to focus on your:

• Stance or posture
• Grip on the handle
• Guiding or free hand

Do not:

• Leave sharp knives loose in a drawer.

• Put knives in the sink.
• Use a knife as a can opener.
• Carry knives while carrying other objects.
• Engage in horseplay with a knife.
• Carry a knife in your pocket.
• Run your fingers down the edge of a knife to test the sharpness.
• Attempt to catch a falling knife.
• Put in the dishwasher.
Washing knives
To prevent rusting and cross contamination, always wash and dry your knife immediately after you
have finished using it. Do not let knives soak, especially if they have wood handles as the wood
can expand when soaked in water.

Storing your knives

Store them in a special knife rack or wooden block. This way you can help keep the blades sharp
by keeping the edges away from hard objects that can dull the blades.

Hot holding and cold holding food

If you are holding foods for service, such as on a buffet line or in a cafeteria, then try to keep hot
foods hot and cold foods cold. Hot holding equipment along with chafing dishes, slow cookers,
and warming trays all help to keep ready to eat food out of the danger zone. All of this equipment
is for hot holding only, and should not be used to reheat or cook food.

Tips:

• Preheat hot holding equipment before you put any food in it. If you don’t then you’ll be
putting food into cold equipment which encourage bacteria growth.
• Limit the hot holding of food to a maximum of two hours.
• To distribute the heat evenly, make sure to stir the food at regular intervals.
• Keep the food covered, this not only retains the heat but also stops contaminates from
falling into the food.
• Bring out the food as close as possible to the time of service.
• Keep platters refrigerated until it is time to warm them up for serving.

Pot handles
Turn pot handles away from the front of the stove. This stops children from grabbing them, and
adults from accidentally bumping into them.

Perishable foods
After, a delivery always unload perishable foods first and immediately refrigerate them.

Using kitchen appliances

• Make sure that all necessary guards are in place before operating any equipment.
• Do not distract a colleague who is operating dangerous kitchen appliances like mincers or
mixers etc.
• Do not to operate any machinery or use any chemical until it has been assessed by a
qualified person.
• Make sure you are properly trained to use any kitchen appliances.
• Wash and put away appliances that are not being used, do not leave them lying around.
• Return equipment to it’s correct storage place or location.
• Turn off all equipment and appliances at the end of each shift.

Children and non food workers

Do not allow children, and people not involved in any cooking to roam or loiter around a food
preparation area.
Work surfaces
Make sure that work surfaces and equipment are visually clean, this goes a long way towards
ensuring that they are free from high levels of harmful bacteria.

Clean as you go
Train yourself to ‘clean as you go’, for instance cleaning up any spillages immediately.

Cans
Before opening a can of food always clean the top of it first. Remember that once the can is
opened, any food which is not used immediately must be quickly stored in food grade containers
and placed in a refrigerator.
Can openers
Food can be left on any can opener after it has been used, it’s therefore advisable to clean it after
each use.

Plates
Never place cooked food on a unwashed plate that had previously held raw meat, poultry, or
seafood.

Food labels
Take the time to read product labels very carefully, and look for advisory statements like ‘may
contain ingredient X’.

Ovens
Close oven doors straight after removing or adding food items.

Meat and poultry

Keep meat and poultry in its packaging until just before using.

Towels and sponges

• Replace and wash dish towels and sponges often to prevent the spread of harmful bacteria
throughout the kitchen.
• Do not use damp cloths when lifting hot items of equipment.

Uncovered food
Try not to leave food unattended or uncovered for long periods.

Cutting boards
Use separate cutting boards, dishes, utensils and cooking equipment for vegetables, raw meat
and cooked meats.

Plates
When handling plates and trays do not touch eating surfaces with fingers.

Unused sauces
Keep unused condiments, marinades and sauces separate from leftover ones.
 Storing food in the fridge
Store raw meat, poultry and seafood by tightly wrapping it and then placing it on the bottom shelf
of a refrigerator. This basically prevents the raw juices from dripping on other food.

• Refrigerate or freeze perishables, prepared food and leftovers within 2 hours.

Jewellery
Do not wear any watches, rings, bracelets or other jewellery when working with food. Germs can
hide under them or just as worse they could accidentally fall off into the food.

Mitts
Use oven mitts when taking hot dishes from an oven or microwave. Do not use a wet oven mitt, as
it can present a scald danger if the moisture in the mitt is heated.

Chapter 4

First aid and handling emergencies

It’s important to :

• Know how to get help.

• Make sure the area is safe for the child.
• When possible, personal protective equipment (such as gloves) should be used.
• Position the child appropriately if her airway needs to be opened or CPR
(cardiopulmonary resuscitation) is needed.
• NOT MOVE A CHILD WHO MAY HAVE A NECK OR
BACK INJURY (from a fall, motor vehicle crash, or other injury or if the child says his neck or back
hurts) unless the child is in danger.
• Look for anything (such as emergency medical
identification jewelry or paperwork) that may give you
information about health problems.

Stings, Bites & Allergies

• Stinging Insects: Remove the stinger as soon as possible with a scraping motion using a
firm item (such as the edge of a credit card). Put a cold compress on the bite to relieve the
pain. If trouble breathing; fainting; swelling of lips, face, or throat; or hives over the entire
body occurs, call your local emergency number right away. For hives in a small area,
nausea, or vomiting, call the pediatrician. For spider bites, call the pediatrician or Poison
Help. (Have the pediatrician check any bites that become red, warm, swollen, or painful.
• Animal or Human Bites: Wash the wound well with soap and water. Call the pediatrician.
The child may need a tetanus or rabies shot or antibiotics.
 • Ticks: Use tweezers or your fingers to grasp as close as possible to the head of the tick
and briskly pull the tick away from where it is attached. Call the pediatrician if the child
develops symptoms such as a rash or fever.
• Snake Bites: Take the child to an emergency department if you are unsure of the type of
snake or if you are concerned that the snake may be poisonous. Keep the child at rest. Do
not apply ice. Loosely splint the injured area and keep it at rest, positioned at or slightly
below the level of the heart. Identify the snake if you can do so safely. If you are not able to
identify the snake but are able to kill it safely, take it with you to the emergency department
for identification.
• Allergy: Swelling, problems breathing, and paleness may be signs of severe allergy. Call
your local emergency number right away. Some people may have emergency medicine for
these times. If possible, ask about emergency medicine they may have and help them
administer it if necessary.

Fever
Fever in children is usually caused by infection. It also can be caused by chemicals, poisons,
medicines, an environment that is too hot, or an extreme level of overactivity.

Take the child's temperature to see if he has a fever. Most pediatricians consider any thermometer
reading 100.4°F (38°C) or higher as a fever. However, the way the child looks and acts is more
important than how high the child's temperature is.

Call the pediatrician right away if the child has a fever and:

• Appears very ill, is unusually drowsy, or is very fussy

• Has other symptoms such as a stiff neck, a severe headache, severe sore throat, severe
ear pain, an unexplained rash, repeated vomiting or diarrhea, or difficulty breathing
• Has a condition causing immune suppression (such as sickle cell disease, cancer, or
chronic steroid use)
• Has had a first seizure but is no longer seizing
• Is younger than 3 months (12 weeks) and has a temperature of 100.4°F (38°C) or higher •
Has been in a very hot place, such as an overheated car

To make the child more comfortable, dress the child in light clothing, give the child cool liquids
to drink, and keep the child calm. The pediatrician may recommend fever medicines. Do NOT
use aspirin to treat a child's fever. Aspirin has been linked with Reye syndrome, a serious
disease that affects the liver and brain.

Skin Wounds
Make sure the child is up to date for tetanus vaccination. Any open wound may need a
tetanus booster even when the child is currently immunized. If the child has an open wound,
ask the pediatrician if the child needs a tetanus booster.
 • Bruises: Apply cool compresses. Call the pediatrician if the child has a crush injury, large
bruises, continued pain, or swelling. The pediatrician may recommend acetaminophen for
pain.
• Cuts: Rinse small cuts with water until clean. Use direct pressure with a clean cloth to stop
bleeding and hold in place for 1 to 2 minutes. If the cut is not deep, apply an antibiotic
ointment; then cover the cut with a clean bandage. Call the pediatrician or seek emergency
care for large or deep cuts, or if the wound is wide open. For major bleeding, call for help
(911 or your local emergency number). Continue direct pressure with a clean cloth until
help arrives.
• Scrapes: Rinse with clean, running tap water for at least 5 minutes to remove dirt and
germs. Do not use detergents, alcohol, or peroxide. Apply an antibiotic ointment and a
bandage that will not stick to the wound.
• Splinters: Remove small splinters with tweezers; then wash until clean. If you cannot
remove the splinter completely, call the pediatrician.
• Puncture Wounds: Do not remove large objects (such as a knife or stick) from a wound.
Call for help (your local emergency number). Such objects must be removed by a doctor.
Call the pediatrician for all puncture wounds. The child may need a tetanus booster.
• Bleeding: Apply pressure with gauze over the bleeding area for 1 to 2 minutes. If still
bleeding, add more gauze and apply pressure for another 5 minutes. You can also wrap an
elastic bandage firmly over gauze and apply pressure. If bleeding continues, call for help
(your local emergency number).

Eye Injuries

If anything is splashed in the eye, flush gently with water for at least 15 minutes.. Any injured or
painful eye should be seen by a doctor. Do NOT touch or rub an injured eye. Do NOT apply
medicine. Do NOT remove objects stuck in the eye. Cover the painful or injured eye with a paper
cup or eye shield until you can get medical help.

Fractures & Sprains

If an injured area is painful, swollen, or deformed, or if motion causes pain, wrap it in a towel or
soft cloth and make a splint with cardboard or other firm material to hold the arm or leg in place.
Do not try to straighten. Apply ice or a cool compress wrapped in thin cloth for not more than 20
minutes. Call the pediatrician or seek emergency care. If there is a break in the skin near the
fracture or if you can see the bone, cover the area with a clean bandage, make a splint as
described above, and seek emergency care.

If the foot or hand below the injured part is cold or discolored (blue or pale), seek emergency care
right away.

Burns & Scalds

• General Treatment: First, stop the burning process by removing the child from contact
with hot water or a hot object (for example, hot iron). If clothing is burning, smother flames.
Remove clothing unless it is firmly stuck to the skin. Run cool water over burned skin until
the pain stops. Do not apply ice, butter, grease, medicine, or ointment.
 • Burns with Blisters: Do not break the blisters. Ask the pediatrician how to cover the burn.
For burns on the face, hands, feet, or genitals, seek emergency care.
• Large or Deep Burns: Call your local emergency number. After stopping and cooling the
burn, keep the child warm with a clean sheet covered with a blanket until help arrives.
• Electrical Burns: Disconnect electrical power. If the child is still in contact with an
electrical source, do NOT touch the child with bare hands. Pull the child away from the
power source with an object that does not conduct electricity (such as a wooden broom
handle) only after the power is turned off. ALL electrical burns need to be seen by a doctor.

Nosebleeds
Keep the child in a sitting position with the head tilted slightly forward. Apply firm, steady pressure
to both nostrils by squeezing them between your thumb and index finger for 5 minutes. If bleeding
continues or is very heavy, call the pediatrician or seek emergency care.

Teeth
• Baby Teeth: If knocked out or broken, apply clean gauze to control bleeding and call the
pediatric or family dentist.
• Permanent Teeth: If knocked out, handle the tooth by the top and not the root (the part
that would be in the gum). If dirty, rinse gently without scrubbing or touching the root. Do
not use any cleansers. Use cold running water or milk. Place the tooth in egg white or
coconut water or, if those are unavailable, milk, saline solution (1 teaspoon of table salt
added to 8 ounces of water), or water, and transport the tooth with the child when seeking
emergency care. If the tooth is broken, save the pieces in milk. Stop bleeding using gauze
or a cotton ball in the tooth socket and have the child bite down. Call and go directly to the
pediatric or family dentist or an emergency department.

Convulsions, Seizures
If the child is breathing, lay her on her side to prevent choking. Call 911 or your local emergency
number for a prolonged seizure (more than 5 minutes).

Make sure the child is safe from objects that could injure her. Be sure to protect the child’s head.
Do not put anything in the child's mouth. Loosen any tight clothing. Start rescue breathing if the
child is blue or not breathing.

Head Injuries

DO NOT MOVE A CHILD WHO MAY HAVE A SERIOUS HEAD, NECK, OR BACK INJURY. This
may cause further harm.

Call your local emergency number right away if the child:

• Loses consciousness
• Has a seizure (convulsion)
• Experiences clumsiness or inability to move any body part
• Has oozing of blood or watery fluid from ears or nose
 • Has abnormal speech or behavior

Call the pediatrician for a child with a head injury and any of the following symptoms:

• Drowsiness
• Difficulty being awakened
• Persistent headache or vomiting
For any questions about less serious injuries, call the pediatrician.

Poisons
If the child has been exposed to or ingested a poison, call your local emergency services.
• Swallowed Poisons: Any nonfood substance is a potential poison. Do not give anything
by mouth or induce vomiting. Call Poison Help right away. Do not delay calling, but try to
have the substance label or name available when you call.
• Fumes, Gases, or Smoke: Get the child into fresh air and call, the fire department, or your
local emergency number. If the child is not breathing, start CPR and continue until help
arrives.
• Skin Exposure: If acids, lye, pesticides, chemicals, poisonous plants, or any potentially
poisonous substance comes in contact with a child's skin, eyes, or hair, brush off any
residual material while wearing rubber gloves, if possible. Remove contaminated clothing.
Wash skin, eyes, or hair with a large amount of water or mild soap and water. Do not
scrub.

If a child is unconscious, becoming drowsy, having convulsions, or having trouble breathing,

call your local emergency number. Bring the poisonous substance (safely contained) with you
to the hospital.

Fainting
Check the child's airway and breathing. If necessary, call your local emergency services and begin
rescue breathing and CPR.

If vomiting has occurred, turn the child onto one side to prevent choking. Elevate the feet above
the level of the heart (about 12 inches).

Learn & Practice CPR

If alone with a child who is choking:

• SHOUT FOR HELP.

• START RESCUE EFFORTS.
• CALL YOUR LOCAL EMERGENCY NUMBER.

Start first aid for choking If:

• The child cannot breathe at all (the chest is not moving up and down).
• The child cannot cough or talk or looks blue.
 • The child is found unconscious/unresponsive.

Do not start first aid for choking if:

• The child can breathe, cry, or talk.

• The child can cough, sputter, or move air at all. The child's normal reflexes are working to
clear the airway.
•
For Infants Younger than 1 Year:
• Infant Choking: If the infant is choking and is unable to breathe, cough, cry, or speak,
follow these steps. Have someone call 911. o GIVE 5 BACK BLOWS (SLAPS).
o ALTERNATING WITH o GIVE 5 CHEST COMPRESSIONS.
o Alternate back blows (slaps) and chest compressions until the object is dislodged
or the infant becomes unconscious/unresponsive. If the infant becomes
unconscious/unresponsive, begin CPR.

• Infant CPR: To be used when the child is UNCONSCIOUS/UNRESPONSIVE or when

breathing stops. Place child on flat, hard surface. o START CHEST COMPRESSIONS.
§ Place 2 fingers of 1 hand on the breastbone just below the nippleline.
§ Compress chest at least 1/3 the depth of the chest, or about 4cm
(1.5inches).
§ After each compression, allow chest to return to normal position. Compress
chest at rate of at least 100 times per minute.
§ Do 30 compressions.
o OPEN AIRWAY.
§ Open airway (head tilt–chin lift).
§ If you see a foreign body, sweep it out with your finger. Do NOT
do blind finger sweeps. o START RESCUE BREATHING.
§ Take a normal breath.
§ Cover infant's mouth and nose with your mouth.
§ Give 2 breaths, each for 1 second. Each breath should make
the chest rise. o RESUME CHEST COMPRESSIONS.
§ Continue with cycles of 30 compressions to 2 breaths.
§ After 5 cycles of compressions and breaths (about 2minutes)
and if no one has called 911 or your local emergency number, call it yourself.
For Children 1 to 8 Years of Age:
Child choking (Heimlich Maneuver): Have someone call the emergency services. If the child is
choking and is unable to breathe, cough, cry, or speak, follow these steps.

• Perform Heimlich maneuver.

• Place hand, made into a fist, and cover with other hand just above the navel. Place well
below the bottom tip of the breastbone and rib cage.
• Give each thrust with enough force to produce an artificial cough designed to relieve
airway obstruction.
 • Perform Heimlich maneuver until the object is expelled or the child becomes
unconscious/unresponsive.
• If the child becomes UNCONSCIOUS/UNRESPONSIVE, begin CPR.

Child CPR: To be used when the infant is UNCONSCIOUS/UNRESPONSIVE or when breathing

stops. Place infant on flat, hard surface.

• START CHEST COMPRESSIONS. o Place the heel of 1 or 2 hands over the lower half of
the sternum.
o Compress chest at least 1/3 the depth of the chest, or about 5 cm (2 inches).
o After each compression, allow chest to return to normal position. Compress chest
at rate of at least 100 to 120 times per minute.
o Do 30 compressions.
• OPEN AIRWAY. o Open airway (head tilt–chin lift).
o If you see a foreign body, sweep it out with your finger. Do NOT do blind finger
sweeps.
• START RESCUE BREATHING. o Take a normal breath. o Pinch the child's nose closed,
and cover child's mouth with your mouth.
o Give 2 breaths, each for 1 second. Each breath should make the chest rise.
• RESUME CHEST COMPRESSIONS. o Continue with cycles of 30 compressions to
2breaths until the object is expelled.
o After 5 cycles of compressions and breaths (about 2 minutes) and if no one has
called 911 or your local emergency number, call it yourself.

4.2 Fall and injury

Brain Injury and impact: Minor trauma to the head is common in childhood and does not require
any medical or surgical treatment. Nevertheless, head injury in infancy and childhood is the single
most common cause of death (Luerssen et al., 1988) and permanent disability. Measurable
deficits occur even after mild to moderate head injury but are markedly greater after severe injury.
They include impaired cognition, motor impairments, disruption of attention and information
processing, and psychiatric disturbances (Adelson and Kochanek, 1998). While some head
injuries do cause serious and lasting damage to the brain, it's important to remember that 'head
injury' is a broad term describing a vast array of conditions - ranging from mild to severe. When a
parent hears that their child might have a head injury, their natural instinct is to conjure up the
worst possible scenario. However, while some head injuries do cause serious and lasting damage,
it’s important to remember that “head injury” is a broad term describing many different types of
trauma—ranging from mild to severe. Head injuries can be anything from cuts, bumps and bruises
to concussions, skull fractures and serious brain injuries. Head injuries are common in children
and adolescents of all ages
 Chapter 5

Hygienic care practices especially when handling children in group

situations

Personal hygiene is the action, habit or practice of keeping oneself clean, especially as a means
of maintaining good health. The practice of personal hygiene can also protect the health of others.

Hygiene education in the curriculum

Schools can incorporate hand hygiene education into the curriculum and daily school activities to
maximise opportunities for students to develop personal hygiene practices. See the Clean Hands
hand hygiene curriculum resource in Department resources below.
Hand hygiene should be routinely performed:

• before, during and after preparing food

• before and after eating
• after using the toilet
• after coughing, sneezing or blowing your nose
• after touching animals or pets
• before and after treating a wound or cut
• after handling garbage
• when hands are visibly soiled.

Schools can create a personal hygiene care and learning plan that positively
reinforces progress for students identified with a learning need in the step-by-
step processes of:

• hand hygiene
• face washing, especially after eating
• blowing and wiping their noses
• toileting

TIP 1: MAKE HYGIENE FUN AND EXCITING, Kids are likely to adopt hygienic habits if they enjoy

doing them. Through co-curricular activities and inter-house competitions conducted in schools,

the importance of hygiene can be conveyed in a fun and competitive manner.

TIP 2: HAND-WASHING IS A MUST, Hand washing is an integral aspect of good hygiene. To

eliminate contracting germs after playing outside or when in close contact with animals or

someone who might be ill, it is essential to teach kids to wash their hands thoroughly and

scrubbing their hands with antiseptic cleansers, especially after using the washroom.

TIP 3: GROOMING THEIR FINGERNAILS, Fingernails are a breeding ground for bacteria. The

germs that live under a child's nails are easily transferred to their eyes, nose, and mouth. Ensure

that students' fingernails are clipped every week.

TIP 4: ORAL HYGIENE, Proper brushing and flossing is a learned skill that can only be improved

by practice. This type of oral hygiene needs to be instilled in students at an early age.

TIP 5: HANDKERCHIEF IS THEIR BEST FRIEND, A handkerchief should be a child's best friend.

Children should be taught to cover their mouth and face, using either a handkerchief or a tissue,

while coughing and/or sneezing.

TIP 6: KEEPING TOYS IN THE PLAYROOM GERM-FREE, A child's favourite stuffed toy or

blanket may carry germs. Make sure it is washed with other toys regularly.

TIP 7: CLEANING OF CLASSROOM FURNITURE, Regular cleaning of classroom furniture will

ensure a bug-free learning and teaching environment. Classrooms must be vacuumed and

mopped every day.

TIP 8: FOOT HYGIENE, Sweaty feet, also known as athlete's foot, can cause fungal infection.

Kids should use cotton-lined socks instead of synthetic fibers along with leather and canvas

shoes, to allow feet to breathe.

TIP 9: DEALING WITH ILLNESS, Children should only attend school if they are well enough to

benefit and participate. This will also reduce the chance of illness spreading.

TIP 10: STOP BAD HABITS, Remind kids of the importance of practicing good hygiene.

Explain that, although germs may not be visibly present, they are still found in air particles and

can make them sick.