Preschool Health Services Indicators of quality of Under-five Health Services Presented by: Dr. Soha Rashed Professor of Community Medicine Faculty of Medicine - Alexandria University 2011-2012

Preschool Health Services Preschool children are those aged one to less than six years. In most countries, there is a relative neglect of children of preschool age, where the schedule of work in MCH centers provides only one day per week for preschool children. 1-<6 Y

Characteristics of preschool period High morbidity of infectious and parasitic diseases High prevalence of malnutrition High incidence of injuries High mortality   Growth and development

1. High morbidity of infectious and parasitic diseases Infectious Diseases: Respiratory: e.g., ARI, Chicken Pox, Whooping Cough, German Measles, etc. GIT: e.g., Diarrheal Diseases, Enterica , Hepatitis A. Skin Diseases: e.g., Impetigo, Scabies and Fungal Diseases. Parasitic infections: e.g., Oxyuris and Ascaris.

2. High prevalence of malnutrition Malnutrition is prevalent among preschool children due to:   Hyperactivity and lack of interest in food. Faulty feeding habits. High prevalence of infectious and parasitic diseases .

The most common malnutrition diseases among preschool children are: Protein energy malnutrition (mild, moderate and severe) Micronutrient deficiencies: iron deficiency anemia, vitamin A deficiency and iodine deficiency. Rickets.

Malnutrition in early life affects the physical growth, and is considered a risk factor for mortality from infectious diseases. Severe prolonged malnutrition in the first two years of life is associated with retarded brain growth and mental development, which persists to adult life.

3. High incidence of injuries Preschool children are more prone to injuries as they are curious, energetic and eager to explore the environment. Most injuries occur where children spend the most active portion of their day (home, nursery or playgrounds). Falling downstairs causing head injuries or fractures. Household liquids Ingestion (kerosene, potash , insecticides). Ingestion of drugs. Burns or scalds. Electric shock. Almost all injuries are preventable. Efforts to reduce preschool injury rate should focus on the promotion of safety at homes, kinder gardens and play grounds as regards conditions and practices.  

4. High mortality Child Death Rate Under-five Mortality Rate

5. Growth and development Growth By the end of the second year, the birth weight gets quadrupled. After the second year, the increase is steady at an annual rate of about 2.25 - 2.75 kg in weight and 7.5 cm in height until the adolescent spurt occurs. Development Motor skills are usually more coordinated in the second year relative to the first year. The behavioral development of the child must be assured through emotional and moral stability, that is, a home where he will find bonds of affection and discipline.

Care of preschool children This is the responsibility of MCH centers (urban areas), and Rural Health Centers/Units (rural areas). Care of preschool children includes: Preventive activities Care in illness Treatment of dental problems Nutritional education Health education

I. Preventive activities Why important? Events in early life (nutritional status and infections) can affect health as the child is growing up to an adult. Many health problems can be prevented through early intervention, e.g. rheumatic heart disease (caused by repeated acute follicular tonsillitis), mental retardation (caused by congenital hypothyroidism). Certain diseases may have their roots in early life. e.g., Rickets, Dental caries, Deafness, Obesity. Some chronic adult orthopedic ailments are probably connected with development anomalies in young children (e.g. congenital dislocation of the hip). Thus, preventive activities are necessary to detect any health deviation, and provide early intervention.

Periodic checkup During the 2nd year of life, at least four visits should be paid to MCH centers or RHU/RHC During the third to sixth years of age, two visits should be paid every year.

Aims of these routine evaluations (periodic check up) are:  1. Assessment of the growth and development of the child using growth charts and developmental tables.  

Growth charts

2. Screening for detection of: Visual defects. Hearing defects. Children with perceptual disorders particularly deafness should be screened as early as possible at least by the end of the second year. Speech defects. Orthopedic defects. Dental appraisal should always be part of the preschool program as milk teeth are important for the growth of permanent teeth, and for the general growth of the jaws. Laboratory investigations, the nature of which depends on the community problems (e.g. blood, urine and stool).   3. Communicable disease prevention: in Egypt, preschool children receive booster doses of Polio, DPT and MMR vaccines at the age of 18-24 months. (Refer to EPI)

II. Care in illness Treatment of minor diseases, and referral of cases needing specialized care. III. Treatment of dental problems IV. Nutritional education It aims at initiating healthy food habits for mothers and children. It requires adequate time, facilities, finance and personnel with practical dietary knowledge. Demonstration kitchens should be present in MCH centers to instruct mothers on how to prepare diet for young children. V. Health education Health education areas should cover growth and development, children needs, communicable disease prevention, diet during infection, injury prevention, family planning, etc.

Indicators of quality of Under-five Health Services Infant Mortality Rate Neonatal Mortality Rate Post neonatal Mortality Rate Child Death Rate Under-five Mortality Rate

1. Infant Mortality Rate IMR It is an age-specific mortality rate. Infant mortality rate is computed using the following formula: IMR=

In Egypt, Infant mortality rate is 19/1000 LB according to WHO (2010). In Malaysia IMR was 6.4/1000 LB in 2008. Infant deaths are related directly to poverty, diseases, bad sanitary conditions, overcrowding and ignorance. Infant mortality rate is a good index for community development in general, and of infant welfare services in particular, as it is a measure of the effect of the different environmental factors surrounding the infant during the first year of life.

The main causes of infant mortality (ordered by frequency) are: ARI (acute respiratory infections; bronchitis and bronchopneumonia). Gastroenteritis and dehydration. Low birth weight and congenital anomalies.

Means of reducing infant mortality Since the etiology of infant mortality is multifactorial, no single intervention can reduce infant mortality. The measures needed for the reduction of infant mortality are classified into general measures and specific measures.

I. General measures Improvement of socioeconomic standards and environmental sanitation. Since mortality of infants is mainly related to environmental and socioeconomic conditions, improvement of nutritional standards, provision of safe water and basic sanitation, improvement of housing, agriculture and industry are all measures that reduce infant mortality. This is why infant mortality is universally recognized not only as the most important indicator of health status of children, but also as an indicator of community development.

Education of females: This can result in delay in the age of marriage prevention of early pregnancy increases women’s awareness regarding personal hygiene, better utilization of health services and family planning services, better care of their children, etc. Studies show that high illiteracy rates are found among women with high infant mortaliy rate.

II- Specific measures Maternal care: Antenatal, natal and postnatal care. Family planning. Adequate maternal nutrition. Infant care: Prevention of infections especially through immunization against the EPI targeted diseases. Early detection and proper management of ARI and gastroenteritis. Breast-feeding and safe weaning practices. Growth monitoring. Special care to LBW (low birth weight) babies.

2. Neonatal Mortality Rate NMR Neonatal mortality rate can be divided into: Early neonatal mortality: deaths in the first week of life. Late neonatal mortality: deaths from 7 to 28 days of life.

The main causes of neonatal mortality are: Low birth weight and prematurity. Congenital anomalies. Asphyxia neonatorum. Birth injuries e.g. head injuries. Neonatal infections: e.g., tetanus neonatorum, neonatal septicemia, neonatal meningitis, neonatal pneumonia and neonatal diarrhea.

Services aiming at reducing neonatal mortality include: Antenatal, natal and postnatal services. Special care of LBW babies. Improving quality of obstetric care to prevent birth injuries and asphyxia. Family planning.

3. Post neonatal Mortality Rate PNMR The main causes of post neonatal mortality are: ARI. Gastroenteritis and dehydration. Congenital anomalies and prematurity. Services aiming at reducing post neonatal mortality include: (Same as what have been discussed in infant mortality rate) I. General measures: Improvement of socioeconomic standards and environmental sanitation and education of females. II. Specific measures: Maternal care and Infant care.

4. Child Death Rate The child death rate is the number of deaths of children aged 1 – 4 years per 1000 children in the same age group in a given year and locality. It thus excludes infant mortality. The child death rate is computed by the following formula: In Malaysia, Child Death Rate was 0.4 per 1000 population aged 1-4 years in 2008.

The main causes of death in children aged 1-4 years old are: ARI Gastroenteritis and dehydration. Other infections coupled with malnutrition. Injuries.

The child death rate is a more refined indicator of the social situation in a country than is the infant mortality rate. It reflects the adverse environmental health hazards (e.g. malnutrition, poor hygiene, infections and injuries) including economic, educational and cultural characteristics of the family. In the age group 1-4 years, the second year is the period when the young child is at highest risk.

5. Under-five Mortality Rate UNICEF defines this as the “annual number of deaths of children age under-five years, expressed as a rate per 1000 live births”. More specifically, it measures the probability of dying between birth and exactly 5 years of age. It is considered as the best single indicator of social development and well being as it reflects income, nutrition, health care and basic education, etc.   Under-five mortality rate is computed by the formula: In Egypt, it is 21.8/1000 LB (2008). In Malaysia, it is 6/1000 LB (2011)

The main causes of under- five mortality rate are: ARI neonatal and perinatal causes Gastroenteritis and dehydration Injuries