Healthy Home

Definition

10 Characteristics of a Healthy Home

1. Dry (Free from Excess Moisture)

2. Clean

3. Well-Ventilated

4. Safe from Physical Hazards

• Secure staircases with handrails
• Non-slip flooring and rugs
• Adequate lighting in all rooms and hallways
• Safely stored chemicals and medications away from children

5. Pest-Free

6. Contaminant-Free

• Lead (from old paint or pipes)
• Asbestos (from old building materials)
• Carbon monoxide (from faulty heating or cooking appliances)
• Radon (a naturally occurring radioactive gas)
• Pesticides and household chemicals

7. Adequate Safe Water Supply

8. Adequate Sanitation and Sewage Disposal

9. Thermally Comfortable (Well-Insulated)

10. Adequate Space and Freedom from Overcrowding

Summary Table

Anaemia: Definition, Classification, Causes, Detection, Prevention and Treatment

1. Definition of Anaemia

WHO Cut-Off Points for Diagnosis of Anaemia (Haemoglobin in g/dL, Venous Blood)

2. Classification of Anaemia

A. By Severity (WHO Grading)

B. By Aetiology (Cause)

C. By Morphology (RBC Size)

3. Causes of Anaemia Among Women

A. Dietary/Nutritional Causes

• Inadequate dietary iron intake - most habitual diets contain iron with less than 5% absorption due to poor bioavailability
• Poor diet quality - low in iron-rich foods (green leafy vegetables, meat, pulses)
• Vitamin B12 deficiency (vegetarian/vegan diets)
• Folate (folic acid) deficiency - especially during pregnancy
• Poor absorption of iron due to consumption of inhibitors (tea, coffee, phytates, calcium)

B. Blood Loss

• Menstruation - regular monthly blood loss depletes iron stores significantly
• Menorrhagia (heavy or prolonged menstrual bleeding)
• Gastrointestinal bleeding (peptic ulcer, worms)
• Blood loss during childbirth (delivery haemorrhage)

C. Increased Demand

• Pregnancy - greatly increased iron and folate requirements
• Lactation - continued iron demand after delivery
• Frequent pregnancies at close intervals - the body cannot replenish stores fast enough
• Adolescent growth spurt combined with menstruation onset

D. Infections and Parasites

• Malaria - destroys RBCs directly (haemolysis)
• Hookworm infestation (Ancylostoma duodenale, Necator americanus) - causes chronic intestinal blood loss
• Roundworm (Ascaris) - competes for nutrients
• Repeated infections impairing immunity and nutrition

E. Socioeconomic and Cultural Factors

• Low socioeconomic status and poverty - inability to afford iron-rich foods
• Food taboos and gender discrimination in food distribution
• Low literacy and lack of health awareness
• Early marriage and early/frequent childbearing
• Poor access to health services

F. Other Medical Causes

• Chronic kidney disease
• Hypothyroidism
• Sickle cell disease, thalassaemia (inherited)
• G6PD deficiency

4. Detection of Anaemia at the Sub-Center Level

A. Clinical (Non-Laboratory) Methods

• Palms (palmar pallor) - most reliable
• Conjunctivae (inner lining of lower eyelids) - pale/white instead of pink-red
• Tongue - pale
• Nail beds - pale
• Oral mucosa (gums/lips)

• Simple, portable haemoglobinometer (Sahli's haemoglobinometer)
• A drop of blood is added to N/10 HCl in a graduated tube
• The colour is compared to a standard brown glass comparator
• Affordable and usable at sub-center level - gives Hb in g/dL
• Limitation: Accuracy depends on the operator's color perception

• WHO-developed Haemoglobin Colour Scale uses filter paper soaked with blood
• The dried blood spot is matched visually against a laminated colour chart (8 shades representing 4, 6, 8, 10, 12, 14 g/dL)
• Simple, cheap, no electricity or laboratory needed
• Suitable for field/sub-center screening

• Fatigue and weakness
• Breathlessness on exertion
• Palpitations
• Dizziness/fainting
• Headache
• Oedema of feet (in severe anaemia)
• History of menorrhagia, multiple pregnancies, worm infestation

• At the sub-center, all pregnant women are registered and screened for anaemia at least twice during pregnancy (first ANC contact and 36 weeks)
• Haemoglobin estimation is part of the focused ANC package

5. Preventive Measures Against Anaemia

A. Dietary Measures

• Increase dietary iron intake: Encourage iron-rich foods - green leafy vegetables (spinach, methi, amaranth), legumes (lentils, beans), jaggery, sesame seeds, flesh foods
• Improve iron bioavailability: Consume Vitamin C-rich foods (lime, amla, citrus) with iron-rich foods to enhance absorption
• Reduce iron absorption inhibitors: Reduce intake of tea, coffee immediately before/after meals; avoid excessive calcium supplementation at the same time as iron
• Promote diversified diet and discourage food taboos that deny women nutritious food

B. Iron and Folic Acid (IFA) Supplementation

• Pregnant women: 1 tablet daily of 100 mg elemental iron + 0.5 mg folic acid, continued until 2-3 months after delivery
• Lactating mothers: IFA supplementation continued for 3 months post-delivery
• Adolescent girls: IFA supplementation - 1 tablet weekly (preventive) or daily (treatment) under the Weekly Iron Folic Acid Supplementation (WIFS) Programme
• Children 6 months - 5 years: Liquid IFA (ferrous sulphate drops)
• If Hb is 10-12 g/dL - daily IFA supplementation; if Hb < 10 g/dL - refer to PHC

C. Control of Infections

• Deworming: Mebendazole (400 mg) or Albendazole (400 mg) given twice yearly to children, adolescents, and women of reproductive age - especially in hookworm-endemic areas
• Malaria prevention: Insecticide-treated bed nets, indoor residual spraying, early diagnosis and treatment
• Immunization: To reduce infectious disease burden which worsens anaemia

D. Iron Fortification

• Use of iron-fortified salt (double-fortified salt with iodine and iron)
• Iron fortification of staple foods (flour, rice) by the food industry
• NIN (National Institute of Nutrition) studies showed iron-fortified salt reduced anaemia prevalence significantly

E. Sanitation and Hygiene

• Improved sanitation (toilets/latrines) reduces hookworm and other soil-transmitted helminth infections
• Safe drinking water prevents waterborne infections that exacerbate anaemia
• Handwashing hygiene to reduce repeated infections

F. Health Education and Behaviour Change Communication (BCC)

• Educate women and families about iron-rich foods, cooking methods (iron pots), and importance of IFA compliance
• Address myths and food taboos
• Counsel women about spacing pregnancies (at least 2-3 years between births)
• Promote early antenatal registration

G. National Programmes

• Anaemia Mukt Bharat (AMB) Programme: India's strategy targeting 6 beneficiary groups (children 6-59 months, 5-9 years, adolescents 10-19 years, pregnant women, lactating mothers, women of reproductive age 15-49 years)
• WIFS (Weekly Iron Folic Acid Supplementation) for adolescent girls in school and out-of-school settings
• National Nutritional Anaemia Prophylaxis Programme (NNAPP)

6. Treatment of Anaemia

A. Mild to Moderate Anaemia (Hb 7-11.9 g/dL)

• Drug of choice: Ferrous sulphate (most absorbed, cheapest)
• Dose for adults/pregnant women: Ferrous sulphate 300 mg (containing 60 mg elemental iron) THREE times daily = 180 mg elemental iron/day
• The IFA tablet under national programme contains 100 mg elemental iron + 0.5 mg folic acid - one tablet daily
• Iron should be taken on an empty stomach (or with Vitamin C) for best absorption
• Side effects: Nausea, constipation, black stools (tell patient this is normal)
• Continue for 3-6 months after Hb returns to normal to replenish stores
• Repeat Hb estimation at 3-4 month intervals to monitor progress

• Especially in megaloblastic/folate-deficiency anaemia
• 5 mg folic acid daily (therapeutic dose)
• 0.4-0.5 mg daily (prophylactic dose in pregnancy)

• 1000 mcg cyanocobalamin IM injection (initial), then maintenance doses

B. Severe Anaemia (Hb < 7 g/dL, especially in pregnancy)

• Parenteral iron: Iron sucrose or ferric carboxymaltose IV/IM when oral iron is not tolerated or not absorbed fast enough
• Blood transfusion: For life-threatening anaemia (Hb < 4-5 g/dL), in patients with severe symptoms, or before emergency surgery/delivery
• Refer to higher facility (PHC/CHC/District Hospital)
• If Hb < 10 g/dL at sub-center, refer to nearest PHC immediately

C. Treatment of Underlying Cause

• Deworming: Mebendazole 400 mg single dose or Albendazole 400 mg (given along with IFA)
• Malaria treatment: Antimalarials (artemisinin-based combination therapy for P. falciparum)
• Treatment of menorrhagia: Hormonal therapy, referral to gynecologist
• Dietary counselling: Ongoing nutritional education

D. Monitoring

• Re-check Hb after 4 weeks of treatment - expect rise of 1-2 g/dL per month with adequate oral iron
• If no response, evaluate for compliance, absorption problems, ongoing blood loss, or wrong diagnosis

Summary

Malnutrition: Definition, Classification, Causes, Prevention and Treatment

1. What is Malnutrition?

1. Undernutrition - too little food, energy, or nutrients (protein, vitamins, minerals)
2. Overnutrition - too much food, energy, or certain nutrients (obesity, diet-related diseases)

• Low birth weight (if the mother is malnourished)
• Poor growth in children
• High mortality in children between 12-24 months of age
• It is an underlying cause in approximately 30% of deaths among children under 5 years.

2. Classification of Malnutrition

A. WHO Broad Classification

B. By Nutritional Deficiency

i. Protein-Energy Malnutrition (PEM)

ii. Micronutrient Malnutrition (Hidden Hunger)

• Iron deficiency → Anaemia
• Vitamin A deficiency → Night blindness, xerophthalmia, childhood blindness
• Iodine deficiency → Goitre, cretinism, mental retardation
• Zinc deficiency → Poor growth, impaired immunity
• Vitamin D deficiency → Rickets

iii. Overnutrition / Obesity

• Excess calorie intake leading to overweight and obesity
• Associated with diabetes, hypertension, heart disease

C. Anthropometric Classification (Gomez Classification) - based on weight for age

D. Waterlow Classification (Wasting and Stunting)

3. Causes of Malnutrition in India

A. Immediate Causes

1. Inadequate dietary intake - insufficient food, poor quality diet, low protein and calorie content
2. Frequent infections - diarrhoea, respiratory infections, measles, malaria, tuberculosis create a vicious cycle (infection worsens malnutrition and malnutrition worsens infection)
3. Poor feeding practices - early cessation of breastfeeding, improper weaning, replacement of breast milk with watery gruels (rice water, thin gruel)
4. Low birth weight - babies born to malnourished mothers start life already compromised

B. Underlying Causes

Socioeconomic

• Poverty - inability to afford adequate, diverse food
• Food insecurity - seasonal food shortages, inadequate food production
• Inequitable food distribution within families - women and children often eat last and least

Maternal Factors

• Maternal malnutrition - a malnourished mother produces a low birth weight baby
• Young maternal age (< 18 years) or older age (> 35 years)
• Short birth intervals (< 2 years between pregnancies)
• High parity (more than 4 children) - depletes maternal nutrition
• Inadequate antenatal care

Family and Social Factors

• Large family size - studies show malnutrition prevalence increases in families with > 4 children
• Mother's illiteracy - less knowledge about child feeding and hygiene
• Gender discrimination - girl children often receive less food
• Food taboos and cultural practices - restricting nutritious foods for pregnant women and children
• Early marriage and early childbearing

Environmental Causes

• Poor sanitation and safe water - leads to repeated diarrhoeal infections, worm infestations (hookworm, roundworm)
• Overcrowding - increases transmission of infectious diseases
• Unhygienic conditions - poor food storage and preparation practices

National/Systemic Causes

• Inadequate health services reach in rural areas
• Poor immunization coverage - children fall sick repeatedly
• Lack of nutrition education and awareness
• Unequal distribution of food nationally
• Agricultural policies not focused on food security

4. Prevention Strategies for Malnutrition

A. Nutritional Interventions

• Promotion of exclusive breastfeeding for the first 6 months of life (breast milk alone is adequate)
• Timely, adequate, and safe complementary feeding from 6 months onwards (semi-solid foods + continued breastfeeding up to 2 years)
• Dietary diversification - include locally available, affordable, nutritious foods (eggs, legumes, green leafy vegetables, milk)
• Micronutrient supplementation - Vitamin A supplementation (biannual doses to children 6 months - 5 years), Iron-Folic Acid (IFA), Zinc

B. Growth Monitoring and Promotion

• Regular weighing of children (monthly at anganwadi centres using ICDS growth charts)
• Early identification of faltering growth and appropriate action
• Mid Upper Arm Circumference (MUAC) measurement for field screening

C. Control of Infections

• Immunization - complete immunization against vaccine-preventable diseases (measles, diphtheria, pertussis, etc.)
• Oral Rehydration Therapy (ORS) for diarrhoea - prevents nutrition loss
• Deworming - Albendazole twice yearly to reduce helminth-related nutrition losses
• Malaria prevention - bed nets, spraying

D. Sanitation and Water Supply

• Access to safe drinking water
• Proper disposal of excreta (toilets)
• Handwashing with soap before feeding children and after defecation
• Safe food storage and preparation

E. Maternal Nutrition

• Improve nutritional status of women BEFORE and DURING pregnancy
• Promote adequate spacing between births (at least 2-3 years)
• Antenatal care with IFA supplementation, deworming, dietary counselling
• Discourage early marriage

F. National Programmes in India

• ICDS (Integrated Child Development Services) - supplementary nutrition, immunization, health check-up, referral, nutrition education at anganwadi centres
• PM POSHAN (Mid-Day Meal Scheme) - nutrition for school children
• Poshan Abhiyaan (National Nutrition Mission) - aims to reduce stunting, wasting, low birth weight
• WIFS (Weekly Iron Folic Acid Supplementation) for adolescent girls
• Village Health and Nutrition Days (VHND) - monthly platform for antenatal care, immunization, growth monitoring
• Nutritional Rehabilitation Centres (NRCs) - for management of Severe Acute Malnutrition (SAM)

G. Education and Behaviour Change Communication (BCC)

• Educate mothers about appropriate child feeding, hygiene, and care practices
• Nutrition counselling at sub-center, anganwadi, and PHC level
• Community-based education through health workers (ASHA, ANM, Anganwadi Worker)

5. Responsibilities of a Health Worker to Prevent Protein Deficiency Disorders in Children

A. Health Education and Counselling

• Counsel mothers on exclusive breastfeeding for 6 months and continued breastfeeding up to 2 years
• Teach proper complementary feeding techniques - when to start, what to give, how much, how often
• Educate about protein-rich locally available foods (eggs, dal, groundnuts, milk, meat)
• Educate on colostrum feeding - first milk is richest in proteins and antibodies
• Counsel against giving only starchy foods (rice water, gruels) after weaning
• Advise against early introduction of diluted cow's milk as the sole diet

B. Growth Monitoring

• Weigh children monthly and plot on growth chart (ICDS growth chart)
• Identify children with faltering growth (flat or downward growth curve) and counsel mothers
• Measure MUAC (Mid-Upper Arm Circumference) - < 115 mm indicates SAM in children 6-59 months
• Identify and refer Grade III/SAM children to NRC or PHC

C. Identification and Referral of Malnourished Children

• Recognise clinical signs of PEM: oedema, wasting, visible severe wasting, hair changes, skin changes
• Refer SAM children (with complications or no appetite) to Nutritional Rehabilitation Centre (NRC) or higher facility promptly
• Follow up children after discharge from NRC for continued community-based management

D. Supplementary Nutrition

• Distribute supplementary nutrition provided under ICDS (Anganwadi Worker)
• Ensure eligible children (6 months - 6 years), pregnant and lactating women receive supplementary food
• Maintain records and ensure regularity of distribution

E. Immunization

• Ensure complete immunization of all children (BCG, DPT, Polio, Measles, Pentavalent) as per national schedule
• Immunization prevents infections that trigger and worsen malnutrition (measles is a common precipitant of kwashiorkor)

F. Deworming

• Administer Albendazole 400 mg (or 200 mg for children 12-24 months) biannually under the National Deworming Day programme
• This reduces hookworm and roundworm burden which rob children of nutrients

G. Management of Diarrhoea

• Prompt treatment of diarrhoea with ORS and zinc to prevent nutritional deterioration
• Continue feeding during illness - teach mothers "never starve a sick child"

H. Maternal Health

• Identify and register all pregnant women early
• Ensure adequate antenatal care, IFA supplementation
• Promote birth spacing and small family norms
• Identify and refer malnourished pregnant women for extra nutritional support

I. Record-Keeping and Reporting

• Maintain registers of children's weights, growth charts, SAM children
• Report malnourished children to PHC/CHC for intervention
• Monitor trends and ensure no child is lost to follow-up

6. Treatment of Marasmic Kwashiorkor

PHASE 1 - STABILIZATION (Days 1-7)

• Risk of death from low blood sugar
• Give 50 ml of 10% glucose (or 10% sucrose) orally or by nasogastric tube
• Start feeding immediately every 2 hours (day and night) - F-75 formula

• Malnourished children cannot maintain body temperature
• Keep warm with clothing, blankets, skin-to-skin contact (Kangaroo care)
• Warm the room; avoid cold water baths
• Feed immediately

• These children are at high risk of fluid overload and heart failure - IV fluids are dangerous
• Rehydrate with ReSoMal (Rehydration Solution for the Malnourished) - 5-10 ml/kg/hour for 12 hours
• Do NOT use standard ORS (too much sodium)
• Avoid IV fluids unless child is in shock

• All severely malnourished children have excess body sodium and are deficient in potassium and magnesium
• Give extra potassium (3-4 mmol/kg/day) and extra magnesium (0.4-0.6 mmol/kg/day)
• Add to food - do NOT give IV potassium

• Even without obvious signs, assume there is hidden infection
• Give broad-spectrum antibiotics:
  • Amoxicillin orally (if no complications)
  • Ampicillin + Gentamicin IV (if complications: shock, pneumonia, severe anaemia)
• Treat other infections (malaria, TB) if suspected
• Avoid live vaccines until child is in recovery

• Give Vitamin A on Day 1 (high dose - 200,000 IU for > 1 year; 100,000 IU for 6-12 months)
• Give folic acid (5 mg on Day 1, then 1 mg/day)
• Give zinc (2 mg/kg/day) and copper (0.3 mg/kg/day)
• Give multivitamin supplement (especially B-complex vitamins)
• Do NOT give iron in stabilization phase - wait until rehabilitation phase (iron stimulates bacterial growth in a sick child)

• Goal: provide 100 kcal/kg/day and 1-1.5 g protein/kg/day
• Use F-75 (75 kcal/100 ml) - a milk-based therapeutic formula
• Give small, frequent feeds every 2-3 hours (8-12 feeds/day)
• Total volume: 100-130 ml/kg/day
• Do NOT give high-calorie feeds initially - risk of heart failure and refeeding syndrome
• If anorexic, use nasogastric tube feeding
• Continue breastfeeding in addition

PHASE 2 - REHABILITATION (Weeks 2-6)

• Transition from F-75 to F-100 (100 kcal/100 ml) over 2-3 days
• F-100 provides 100 kcal/100 ml and 2.9 g protein/100 ml
• Increase feeds gradually to 150-200 kcal/kg/day
• Alternatively, use Ready-to-Use Therapeutic Food (RUTF) - Plumpy'Nut (peanut-based, 500 kcal/sachet) in community-based settings
• Target weight gain: > 8-10 g/kg/day is satisfactory recovery
• Now introduce iron (3 mg/kg/day elemental iron) to correct anaemia
• Gradually introduce blended family foods (mashed, soft, energy-dense)

• Structured play and stimulation sessions (30 minutes/day minimum)
• Tender, loving care - reduce distress, talk and play with child
• Physical activity appropriate to age
• Involve mother/caregiver in all aspects of care and teach them at home

• Discharge criteria: No oedema, weight-for-height > -2 SD (or > 80% of median), good appetite, no medical complications, good weight gain
• Continue RUTF at home for community-based rehabilitation
• Schedule regular follow-up visits at health facility (weekly for 1 month, then monthly)
• Ensure complete immunization
• Continue deworming
• Educate mother on appropriate feeding, hygiene, care practices
• Enrol in supplementary feeding programme (ICDS/NRC)
• Provide Vitamin A, zinc supplementation

Summary of Treatment Phases

Key Dangers to Avoid in Treatment

• Never give IV fluids unless in shock (risk of heart failure)
• Never use standard ORS (use ReSoMal instead)
• Never give iron in stabilization phase
• Never force feed - go slowly to avoid refeeding syndrome
• Never give diuretics for oedema - oedema will resolve with nutrition

Summary Table