Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697801259808.pdf (India)
INTEGRATED NUTRITION EDUCATION - a handbook ५ 1१६ । ae 1 eu Bi ows nt Sern FOOD AND NUTRITION BOARD DEPARTMENT OF FOOD MINISTRY OF FOOD & CIVIL SUPPLIES GOVERNMENT OF INDIA INTEGRATED मं EDUCATION =-A HANDBOOK FOOD AND NUTRITION BOARD DEPARTMENT OF FOOD MINISTRY OF FOOD & CIVIL SUPPLIES GOVERNMENT OF INDIA 1991 “Should it alarm us that an appreciable percentage of our population ह PREFACE from chronic malnutrition?” “Is it in the interest of the nation to neglect the problem of malnutrition which cuts at the root of all efforts for development of human resources?” "Is it feasible for a country like India to create a separate infrastructure at the periphery for providing education for nutrition promotion to the community?"
These and many other similar questions have been engaging the attention of the Government including many other national bodies.

The history of nutrition programmes in the country has passed through various phases such as medical/ctinical phase, food production phase, community development phase; and is now passing through a multi-sectoral phase with emphasis on socic-economics of malnutrition.
Malnutrition being a multi-faceted problem requires a multi-sectoral approach for its solution, Many inputs, including those from the various allied fields, are required for the control and prevention of malnutrition.

Nutrition education of the people is one of the important tools for nutrition promotion.
So far nutrition education has largely been confined to food related aspects only, It has now been recognised that education on ‘Non-food factors’ such as health care, hygiene, environmental sanitation etc.

also is equally important for nutrition promotion of the people.
The Food and Nutrition Board in the Department of Food which has been engaged in nutrition education activities through Its Mobile Food & Nutrition Extension Service since about three decades, is now working towards an Integrated Nutrition Education Approach.
The objective is to equip the community with basic messages on food and nutrition through their contact point, namely, field level functionaries belonging to various sectors of the Government concerned with providing nutrition, health and other welfare services.

This publication on "Integrated Nutrition Education — a Handbook" has been prepared keeping in view the need for a reference material for those interested in training field level functionaries.
It is hoped that this monograph would evoke interest in similar other professionais as well and will serve as a valuable reference document, ACKNOWLE remnaney हि Department deeply appreciates and acknowledges with thanks the contributions provided and efforts made by all those who helped in preparing this Handbook.
= h n o O n A N O D 10, CONTENTS Preface Acknowledgement introduction Nutrition anc Heaith Nutrition Intervention Programmes in India Some Basic Facts about Fooa Care of the Pregnant Woman Care of the Nursing Mother Breast Feeding Feeding Infants Nutritional Needs of Children Growth Monitoring Common Nutritional Deficiency Diseases Management of Diarrhoea immunization Personal Hygiene & Environmental Sanitation Safe Drinking Water Food Hygiene Food Toxicity & Safety Storaye of Foodgrains Conservation of Nutrients during Food preparation Preservation of Fruits & Vegetables Conveying Messages to the Community ANNEXURES 5006 Composition Table Summerising of RDA for Indians {as revised in 1989) Balanced Diets Some Do’s & Don'ts Diet in Common Ailments Explanatory Note on Assessment of Nutritional Deficiencies Bibliography th iV Vi Vil 11 21 29 34 32 47 50 69 192 102 111 122 126 131 141 वा 152 164 168 176 178 179 182 187 191 Chapter-1 INTRODUCTION India has a long standing and proud récord of achievernent in agricullurai research leading to increased food production it also has an outstanding record of nutrition research.
And yet from all accounts, India’s burden of chronic, endemic mainutrition and Ill health continues to be unbearable.
The problem of malnutrition is no longer considered a result of food deficiency or as ahealth problem but recognised as a multi-faceted problem interfering with all etforts for development of human resources, A striking feature in the manifes- tation of malnutrition is the convergence phenomenon, convergence of poverty and unemployment, of disease and illiteracy, of rapid population growth and of environmental degradation.
These in turn are linked to cultural factors, eco- nomic distortions, human inequities and social injustices.

The determinants of mainutrition are, therefore, many — including besides the food factors, the non-food factors also such as health care.

hygiene, environmental sanifation etc.

which have an important bearing on the nutritional status of the people.

Increased food production isanecessary condition but not sufficient in liself to ensure nutrition for ail.
The role of non-food factors is just as important; forexample “immunization” breaks the dangerous partnership between malnutrition and infection while family planning enhances the nutritional well-being of families.

Similarly, sound storage practices at the village level to minimise post-harvest losses of food- grains, sound feeding, weaning and child rearing practices are equally impor- tant for nutrition promotion of the peoole.
Nutrition as an integral part of Developmental Programmes Aiarge number of nutrition interventions have been made in recent years by different sectors which have direct and indirect impact on the nutritional status of the people in the country, While direct nutrition intervention programmes may be effective in solving some specific nutritional deficiencies, for example endemic goitre, xerophthaimia and nutritional anaemia, the vast problem of child undernutrition and malnutrition can only be approached through an overall National Development Strategy, i.e.
by making nutrition as an integral part of various developmental programmes at the periphery.

The mainutrition needs to be recognised as a national prodiem and not asectoral problem.

Thus control of malnutrition is only possible through integrated multi-sectoral strategies.
Need for Integrated Nutrition Education Approach Nutrition education of the people has been recognised since long as-an important tool for nutrition promotion in the country, The Department of Foca has been engaged in imparting nutrition education to the community through its Mobile Food and Nutrition Extension Units in collaboration with the State Governments, Educational Institutes and Voluntary Organisations.

Realising the importance of an integrated approach for the contro!
and prevention of malnutrition, it has become important that educational activities of various sectors such as agriculture, food, health and family welfare, women and child development and education are made comprehensive in nature by imparting education an all these aspects in an integrated manner.

The abjective is to equip ihe community with simple knowledge on various factors which determine the health status of an individual.
In order to provide education on both food and non-food factors anc services to the community simultaneously, the Department is working towards an integrated Nutrition Education Approach in collaboration with the concerned sectors.

The field units of the Depart- mentimpart education and training to the beneficiaries and field ftunctionar- ies On various aspects of food and nutrition, health care, hygiene, environ- mental sanitation, food storage etc.
in collaboration with the concerned agencies at the periphery so that the same is imparted to the community during the course of their routine activities.
The objective is : i) To make the people intensely aware of the importance of adequate nutrition for sound physical and mental development: ॥) To educate them in the practical ways of achieving adequate nutrition within their available means by using tn-expensive and locally available food materials; iii) To explain to them the dependence of nutrition on the afore-mentioned different factors and tc impress on them the need to give adequate attention tothe non-food factors also so’as to derive full nutrition from given intake of food; and 1९) To make them fully aware of the existing healtn, nutrition and welfare services/tacilities extended by the State and the benefits that they could have by utilising these services.
Education of Beneficiaries and Communication Strategy T O — — It is not possible for a country to create a separate intrasturcture exclu- sively for providing nutrition education and services to: the community al the peripheral level.

Besides.
Besides.

nutrition being vital for the development of human resources, various Sectors have responsibility towards improving the nutrition of the people, It is, therefore, considered appropriate to utilise the existing infrastructure and the field level functionaries of various Govt.

Departments at the periphery for delivering the educational package to the beneficiaries.
Training and orientation of different level functionaries of the concerned sectors like Health, Women & Child Development, Agriculture & Rural Development, Education etc., therefore.

assumes great importance The field level functionaries like Multi-purpose Health Workers, Auxiliary Nurse Midwives, Lady Health Visitors, Health Educators, Anganwacii Workers, Adult Education Instructors.

Gram Sevikas etc.

would be the agency for imparting education on food and non-food factors to the: com- munity.
These field functionaries var- ious aspects of food, nutrition & health through joint educational camps organised by the field units of the Department at the block or village levei in collaboration with the Medical Officer incharge of the Primary Health Cen- tre and other field agencies.
The Supervisors and trainers of these field functionaries like Assistant Child Development Project Officers, Supervi- sors, Instructors from Anganwadi Training Centres, Health Education Instructors, Adult Education Supervisors, Trainers from Voluntary Organi- sations and other nutrition projects.

would also need io be re-oriented towards integrated approach to nutrition education.
Short-term orientation training courses for nutrition promotion are organised for them by the field units of the Department in collaboration with State level Training Institutes receive intensive training on 9 and Home Science Colleges.

Block and district level officers of the con- cerned Departments are reorientec towards integrated approach to nutri- tion education through block level Worksnops organised by the Department.
Lectures and discussions in these camps, orientation training courses and workshops would be supported by practical demonstrations, film and slide shows and display of exhibits, The inter-personal communication strategy would need to be re-inforced by intensive/repetitive extension publicity through Doordarshan and AIR, The components of Integrated Nutrition Education would be made an integral part of the training pro- grammes already being conducted for such functionaries in Primary Health Centres, Health & Fumily Welfare Training Centres, Medical Colleges, Gram Sevak Training Centres, Home Science Colleges, Agricultural Uni- versities etc.
Purpose of this Hand Book Nutrition is now an important component of training programmes for various health workers and functionaries of Integrated Child Development Services Scheme.

The manuals/guidelines prepared for health workers ICDS workers ete: are designed to train the functionaries to discharge their specific duties.

The existing manuals do not cover the various food anc non-food factors which affect the nutritional status of the people.
The education fer nutrition promotion requires education on all the factors affecting the health of the people in an integrates manner as discussed earlier The purpose of bringing out this hand book ts to provide comore- hensive information on various aspects of food and nutrition, nealth care of vulnerable groups, hygiene, environmental sanitation, food storage etc.

at one place.
at one place.

This hand book, which gives essential information on various food and non-food factors affecting the health of the people which a field level functionary need to know.
has been designed to equip the trainers of nutrition these promotion imparting education for functionaries field level for Starting from the relationship between nutrition and health, functional signif- veance of mainutrition, existing nutrition, health and welfare services in the country and some basic facts about food and nutrition, this hand book covers qutrinonal and health care of young children, pregnant and nursing women, promotion of breast-feeding, education of mothers on feeding infants, growth monitoring.
common nutritional deficiencies and their prevention, manage- ment ol diarrhoea, immunization, personal hygiene and environmental sanita- safe drinking water, food hygiene, food toxicity and safety, storage of tion, igodgrains.

conservation of nutrients dunng food preparation and home scale preservation of fruits and vegetables.

In the-end, the strategies for conveying these messages to the community have been discussed.
It also provides nutri- tive value of common Indian foods, nutritional requirements of various age groups and balanced diets in the Annexures The information in each chapter is presented under various Sub-heads So as to enable the trainers to pian their talks under these heads.

They could also develop simple messages for the field level functionar'es and beneficiaries under each title.
This hand book, though designed for the trainers of field level functionaries, can serve as a reference material for the field fevel fur stionaries after they have received tne training, This can be a very usetul reference materia!

for extension workers in ihe field of nutrition and health 3 Chapter-2 NUTRITION AND HEALTH The problem of malnutrition continues unabated in the country.
It is no longer consisdered a result of food deficiency or as a health problem but recognised as a multifaceted problem interfering with all efforts for develop- ment of human resources.

In order to convince the community about the relationship between nutrition & heaith, functional significance of malnutri- tion and the need for its control, the various aspects of mal-nutrition are discussed under the following sub-heads.
— Relationship between nutrition & health; — Malnutrition — a widespread health problem: — Multitaceted nature of malnutrition problem; — Dimensions of nutritional deficiencies; — Malnutrition and national development; — Consequences of malnutrition; — Measures against malnutrition.

Relationship between Nutrition & Health The health of the people is the wealth of a country, Among various factors affecting the health of the people.

nutrition nas been found to be the most important pre-requisite.
Nutrition and Health are complementary and also in-separable.

These two factors very strongly control the quality of life ofa man specially in the developing countries, While nutrition is regarded as a vital component of health, the latter is an ultimate objective of nutrition.

Mainutrition — a widespread health problem A few years back, the world’s number one health problem used to be either But diseases caused by hostile micro-organisms are small-pox or malaria.

no-longer the prime killers.


Their incidence is declining with the spreed of modern medicine, Malnutrition, in one form or the other, is the most serious For example, over wide-spread health problem now facing the humian race.

nutrition is a greal problem in America while in India, half the population suffers from chronic dietary deficiency.
Thus, we are concerned with wide and mu,t- faceted nature of the problem of malnutrition which plagues our country today, Multifaceted nature of Mainutrition Propiem Why do we have this malnutrition problem ?

The salient reasons behind this unfortunate situation.

which is rather complex and not at all simpie as one sometimes feels, needs to be analysed.
The fact that undernutrition and mainu- trition are due to dietary deficiencies caused by insufficiency of food or poverty ig an over-simplification of the entiie problem, The nutritional status of com- munities, specially their vulnerable young child population, is the end result of many variables interacting with each other, To simplify logical thinking and planning, the concept of “Community Nutrition Level Equation” has been suggested a पिा Food availa-|/Aspects bility Economic) level | infections ली.
लक ee Preventive health अदा पाए level Community levelof Nutrition ७६ Population Size The various items noted in the ‘Community Nutrition Level Equation’ are of For example, food course, short hand for variable and complex situations.

availability covers a wide ranae inciuding intrafamilial distribution, cultural attitudes, seasonal variations etc.

Similarly, the prevention and early manage- ment of infections has a major role in preserving nutritional health in early childhood.
Economic considerations operate both on national and farnily lav- els, becoming increasingly important with progressive urbanisation and dependence on foods that are bought rather than grown Population size ts the ‘Universal denominator forall other components of the equation.

In addition, a number of children and their spacing have both economic and biological relationships with the nutritional status of young children ard also of their mothers.
Cultural factorsalso affect the nutrition of young children and the rest of the community by infiuencing all components of the equation.

Malnutrition is a consequence of socio-sconomic deprivation.

Hence the socio-economic causes of malnutrition have to be eradicated for successful campaign against malnutrition.
The diagram on the next page will throw some light on this complex problem Dimensions of Nutritional Deficiencies Tio Mimoneivanc ni the nistritinnal dafirianricse ie the a7: ; |__ Poverty | __k ‘.

, xen - (literacy ० .

Unhyagienic ae ‘i : ; ‘ ' ; NY Inadequate tooa ; : ~ Superstitions, food taboos | “ | | t : b पर जा infestations t : % Too many closely spaced pregnancies - ‘ ५ 1 vw है ४ ' ‘ ' y : Lew work output i .

4 ' हे 3 (ll-health or १७४७७ .


aime ys : “sl ia MALNUTRITION | -~ pS =p revealed by a large Numbe: of surveys carried out in different parts of the country By and large.

he vulnerable segments of the population consisting of infants, young children, pregnant and lactating mothers are the worst sufferers from the ravages of matnutrition About 70% cf the total number in this vulnera- dle group suffer from various degrees of under-nutrition and malnutrition.
The position of malnutrition at the present moment is that there are large number of creeping, apparently normal, malnutrition cases in the age group of 1-5 years.

This could be termed as "the era of surviving children” in which larger number go nol succumb to severe malnutrition, but are left vulnerable to subsequeni infectious diseases and are unable to achieve optimal benefit from subsequent schoohing.
Among various types of nutritional deficiency diseases, the most important ang wide-spread are — Protein-Eneray Malnutrition (PEM), Vitamin ‘A’ deti- crency, Anaemra and Goitre Protein-Energy Mainutrition The dangers of Protein-Energy Malnutrition in infants and young children in the country have heen repeatedly emphasised.

Neariy 3% of pre-schoo!


child- ren (0-5 years) sufter from severe torms of clinical ma‘nutrition of Kwashiorkar and Marasmu:s type and double this number shows severe weight deficit indica- tive of severe mainutrition (body weight for age less than 60% of the standard weight ) The incidence of malnutation in tichan pre-schoeel chidren according to dody weight deficit (Gomez Ciassification) is given on tne following page.

Average weights of well-to-do Indian children are taken as standard.
6 ६ malnutrition as assessec by growth न is also evident in school-going children (5-10 years) though severe forms of clinical mal- nutrition (Kwashiorkar and Marasmus) are not normaily seen Vitamin ‘A’ Deficiency: Severe manifestation of Vitamin ‘A’ deficiency is wide-spread in young children and is often associated with moderate and severe Protein-Energy Malnutrition The prevalence is more in schoo!

going children than in pre-schoolers and minimal in infants.
There are about 9 million blind people in the country 2% of them being due to malnutrition caused by Vitamin 'A' deficiency.

a condition known as ‘Keratomalacia’.

Representative and carefully controlled surveys indicate thatabout 12,000-14,000 young children in the Southern & Eastern Regions of the country go blind every year as a result of ‘Keratomalacia’.
Studies conducted by National Institute of Nutrition show that 5% of pre-school childrer, and t0% of school-going children belonging to poor socio- economic groups show signs of Vitamin ‘A’ Deficiency Anaemia: Nutriticnal Anaemia caused by certain nutrients deficiencies like !ron anc folic acid takes a heavy toll of young children and pregnant and lactating mothers.

It is estimated that 40%-60% of pre-school!

children are anaemic.


25-30% af women of child bearing age and half of pregnant women in their thirc trimester of pregnancy suffer from anaemia The effects of nutritioinal anaemia on mortality and morbidity in certain segments of the population * needs no emphasis Goitre: The country has 3 long goitre helt, stretching over the entire sub Hima- jayan region ang having a large number cf people living under the risk of endemic goitre caused by iodine deficiency.
The average total prevalence of goitre in the endemic areas of the courtry is about 30%, ranging between 3% to 60% approximately.

Goitre is not just a minor public heaith probiem.

The fact that the off-springs of goitrous parents are prone to be deaf, mutes, cretins and mentally retarded is sufficient to describe this as a social and mental health problem.

Thisis justa briet description of specific nutritional ceficiencies observed clinically.
Inaddition, various other mainfestation of nutritional deficiencies like Ariboflavinosis, Peilagra.

Rickets: Night-blindness are also widely pre- valent in certain regions.

The number ct cases of sub-clinical deficiencies amone children fooking abvicusly normal but having moderately severe bio-chemical and functional changes must be really staggering.
It is not only the clinical ailments from which they suffer but the effect of sych deficiencies On every individual in all walks of life needs consideration.

The absenteeism of workers in the factory lack of interest or power of mental concentration of children to absorb education are some important exam- ples to highlight the effects of matnutrition Malnutrition and National Development: Nutritional health in all age groups represents a national economic asset.

The problem of malnutrition has, therefare.


to be seen in a proper perspec- ~ Weight (kg) — _ _—_ —-— उनकी eo + wm — _ o pei a C H I L D R E N A C C O R D I N G T O B O D Y N _ N .

M , B , R e p o r t f o r t h e y e a r 1 9 8 2 , N I N , I C M R , H y d e r a b a d , - S C H O O L W E I G H T D E F I C 5 0 % S t d , _ | 6 0 % S t d .

= 7 5 % S t d .

9 0 % S t d .


S T A N D A R D N O R M A L 1 7 % 6 % 3 5 % 4 2 % tive.

It is only in recent years that the problem of mainutrition has gone beyond the fields of public health and welfare services and has assumed a wider dimension.

Possibiy for the first time in the history of the country.

the dangers of malnutrition have now been accepted as definite impediments in the national development of the country.
In fact, it is now accepted at the highest policy-making level in the country that the effects of malnutrition are $0 wide-spread and having tentacles on every sphere of human life that all efforts for total economic development will bear no fruit if the menace of malnutrition continues unabated.

It would be unwise to consider the prob- lem as just the sufferings of certain segments of the population in certain regions of the country from the effects of nutritional deficiencies.
The problem is much deeper needing consideration in a very much wider sphere.

The real question is how far malnutrition is adrain on oureconomic resources and how these can be plugged to athieve the desired goal of development.

In fact, nutrition and health are now accepted as important parameters for development.
Consequences of Malnutrition From what has been stated so far, it boils down to the fact that a large percentage of our gigantic population do not get sufficient amount and the result, various forms and degrees of required quality of food and as a matnutrition and undernutrition are precipitated.
The 3 consequences of malnutrition are : i) alarge percentage of sufferers, specially the young ones die either directly or indirectly in association with infection; ii) quite a sizable percentage arepermanentlycrippied for the rest of their lives as being blinded, congenitally deformed, or physically and mentally retarded; and li) the rest suffer from various degrees of malnutrition as a result of which their contribution for the society and the State are greatly reduced The first consideration is for mortality due to malnutrition about which precise information is difficult to obtain for several raasons.
Most often, the victims of malnutrition at the terminal stage succumb to infection which gets a stronghold in a malnourished body.

Quite often, it becomes difficult to distinguish the effects of malnutrition when there are super imposed infections of various types.

The official causes of mortality in young children include mostly infective conditions, most of which have a background of malnutrition.
Chronic diarrhoea, described as a common cause of mortality and morbidity in children, has been proved to be initiated and aggravated by mainutrition.

In any case, mortality from infective conditions is severa!

times more in a mainourished child than ina one whois healthy.

A critical analysis will reveal that malnutrition is the most important singie facior behind the high mortality rate in infants and young children.
What does this mean in terms of economics when a country like india has a very large child population ?

In terms of harsh economics, this isan undesirable economic drag on the country.

This huge segment of the population is virtually non-productive and in no way contributes to the national income, On the other hand, considerable investments are made by the State to protect and develop them.
Before these unfortunate children could be productive and assets for the country, they die and as mentioned earlier, malnutrition singly or in combination with its best ally, infection, is at the root of the tragedy.

This non-productive segment should, therefore, be regarded as unfinished raw materials for ultimate development into able human resources.

In this context, this group of population is quite valuable.

The consideration of the long term effects of malnutrition is even more tragic.
The large number of children who are blinded as a result of malnutrition, millions of young children who lose their full potential of physical and mental growth, thousands of children in the goitre belt who are born with complete mental retardation are only a few examples to indicate what is happening tc our "future citizens of tomorrow”.

In economicterms, notonly they continue to be unproductive in the country but they need further investments for their rehabilitation.
in other words, they continue to be the liabilities of the State tor the rest of their lives.

The third consideration is of a much wider dimension but unfortunately cannot be clearly pinpointed.

These are the insidious effects of malnutrition in causing ill-health.

The ailments caused by malnutrition not only cause absenteeism among workers but definitely retard the productivity ofa worker, A ‘arge volume of scientific evidences are already available on this aspect.
In fact, there is an urgent need to work out the economics of mainutrition, exactly in the way it is being done for tuberculosis and other diseases, Malnutrition 15, therefore, not just a health or welfare problem but it cuts at the root of all our efforts for natiana!

development.

Malnutrition can, therefore, safely be regarded as development impediment.
Measures against Malnutrition At the outset, it would be better to realise that the problem of malnutrition being of acomplex and multifaceted nature, requires.a multi-sectoral approach.

One should realise that the problem is so vast that the measures propounded by each discipline have a strong point and even if a particular measure touches the fringe of the problem, one should feel happy about it.
The Government of India is making a comprehensive approach towards the solution of malnutrition problem in the country, In general, the nutrition programmes and approaches of the Government of India can be broadly divided under the following heads : a) Increasing the production of foodstuffs — not only the foodgrains but protective and quality foods like animal foods; 9) Better utilisation of the food réscurces by taking the help of food technulogy; c) teaching the common man about the better utilisation of the existing g) foods already avaiable; to protect the health of vulnerable segments by taking preventive nutritional against measures deficiency diseases and supplementary feeding of the most vulnerable segments; and prophylaxis specific certain like ®) associated health measures which could indirectly improve the nutrition standards of the people.
Among these measures are the mesures for infections end infestations population contro!
and control of & problem ofso vast a magnitude cannot be solved by the Government alone and, the people, universities, educational institutions and the voluntary agencies are equally important in this fight against therefore, the cooperation of mainutrition 10 Chapter-3 NUTRITION INTERVENTION PROGRAMMES IN INDIA Malnutrition, a major problem has been receiving progressive attention through all the Five Year Plans with further extension and intensification in the Seventh Five Year Plan.
More emphasis has been laid for improving the nutritional status of the weaker and the vulnerable sections of population witha focus on the tribal and the scheduled castes.

Malnutrition, being.a multi-faceted problem, a combination of approaches like supplementary feeding, nutrition education, fortification and enrichment of foods, extending the existing food supplies and health measures are being emphasised in policy making and programme implementation.
lt would be useful to briefly describe the important nutrition programmes being implemented in the country today.

These are described under the different sectors of the Govt, responsible for their implementation as under: DIRECT NUTRITION PROGRAMMES :.

Ministry of Health & Family Welfare i) Prophylaxis programme against blindness due to Vitamin A deficiency.

ii) Prophylaxis programme to prevent nutritional anaemia in mothers.
and children iii) National Goitre Control Programme, Ministry of Human Resource Development (a) Department of Women & Child Development i) Integrated Chitd Development Services Shceme ii) Special Nutrition Programme ii) Balwadi Feeding Programme (b) Department of Education i) Mid-day Meal Programme.

Ministry of Food & Civil Supplies (a) Department of Food i) Nutrition education ang extension ii} Food iil) Production of nutritious foods and beverages.

Programmes.
Programmes.

| INDIRECT NUTRITION PROGRAMMES : Ministry of Health & Family Welfare.

i) Primary Health Care Services.

li) Expanded Programme of Immunization ili) Family Welfare Programme.

Ministry of Food & Civil Supplies (a) Department of Food i) Storage of Foodgrains & General Warehousing.
(b) Department of Civil Supplies i) Public Food Distribution System Ministry of Agriculture & Rural Development (a) Indian Council of Agricultural Research i) Krishi Vigyan Kendras (b) Department of Rural Development i) National Rural Employment Programme (NREP) ii) Rural Landless Employment Guarantee Programme (RLEGP) iii) Integrated Rural Development Programme (IRDP) iv) Training of Rural Youth for Self-Employment (TRYSEM) Nutrition Education, Training and Research Ministry of Health & Family Welfare i) Prophylaxis Programme against blindness due to Vitamin A deficiency.
Initiated during the 4th Five Year Plan, this programme involves children in the age group of 1-5 years whoaregiven an oral dose of 2 lakh IU of Vitamin Ain oil every six months.

The Vitamin A is readily absorbed and stored in the liver from where it is gradually released for the utilisation by the tissues.
In rural areas the programme Is implemented through the primary health centres and its sub-centres while in the urban areas through the Child Welfare Clinics, Family Planning Centres, Hospitals, Maternity Homes etc.

The target for 1989-90 is to cover 300 lakh children.

li) Prophylaxis Programme to prevent Nutritional Anaemia in Mothers and children.

Since nutritional anaemia.


among mothers and pre-school children is a major public health problem, the Government recognised the importance of prophylatic measures like routine supplementation with iron and folic acid te prevent the development of severe forms of anaemia.

Consequently, a National Prophylaxis Programme was launched in 1970.

Expectant and Nursing mothers and pre-school children receive the benefits of this scheme.
All institutions rendering family planning services like PHCs and their sub-centres, maternity and children hospitals, maternity homes, urban centres implement the programme.

The daily recommended dose is one tablet containing 0.1 mg. folic acid and 60 mg. of ferrous sulphate for children.

Expectant and nursing mothers receive daily one tablet containing 0.5 mg folic acid and 180 mg. of ferrous sulphate during the last trimester of pregnancy and first six months after delivery.
For the sake of convenience the drugs are issued for a fortnight or even a month.

The ANM/LHV are required to check on the actual!

intake of the tablets 12 by the mothers and children during their routine home visits.

The target for 1989-90 is to cover 220 lakh women and 300 lakh children.
iii) National Goitre Control Programme The National Gaitre Control Programme was launched by the Government of india towards the end of Second Five Year Plan to tackle the problem of controlling endemic goitre prevalent in various parts of the country.
The programme has three main components, namely survey of goitre in suspected areas to identify endemic goitre area, production and supply of iodised salt to the endemic areas,the resurvey after 5 years of continuous supply of iodised salt in the endemic areas to assess the impact of the control programme.

30% of the people living in the known endemic regions have been covered under this control programme so far.
The present strategy is to supply the entire country iodised salt replacing the edible salt in a phased manner by 1992.

Initially highest priority will be given to the hyper endemic zone Ministry of Human Resource Development (a) Department of Women & Child Development i) Integrated Child Development Services Scheme In order to provide a package of services relating to health, nutrition and educational needs of children below 6 years of age, this programme was launched in 1975.
The programme is administered through the State Governments.

The progressive total of ICDS Projects sanctioned upto 1989-90 is 2452 which includes 236 projects in urban slums in the country, ICDS is an attemptin integrated childhood services as a step towards human resource development ICDS cares for children below 6 years of age.

pregnant women and nursing mothers residing in socially backward villages and urban slums.
The services provided under the (CDS Scheme are — Supplementary nutrition — immunization — Health check up — Referral services — Nutrition and Health education to women — Non-formal pre-school education — Convergence of other supportive services like water supply, Sanitation etc The focal point for the delivery of the ICDS package of services 1s an Anganwadi in every village.

On an average, there is one Anganwadi for > population of about one thousand.
The Anganwadi worker is a iocal woman preferably trom the same village in which she works, A Chitd Development Project Officer (CDPO) Is directly incharge of each ICDS project.
The Block Development Officer has the overall responsibility as for the other schemes in the block, The work of Anganwadi Workers is supervised by Mukhya Sevikas, whose work is in turn supervised by the COPO The Medical Officers, the Lady Health Visitors and the family health workers of the nearby primary health centre form a team with the social welfare functionaries to implement ICDS, ii) Special Nutrition Programme This programme was launched in 1970-71 to provide supplementary feeding 13 forchildren in 0-3 years age group living in tribal areas and urban slums.
and was later extended to children 3-6 years and expectant and nursing mothers.

The daily supplementary nutrition consists of 200-300 calories and 10-129 of protein per child per day and 500 calories and 25 g of protein per mother per day, Supplementary food is provided for 300 days in a year.

During the Fifth Plan the programme was transferred to the State Sector and was included in the Minimum Needs Programme.
The present coverage is about 11.5 million beneficiaries — about 10 milljon iniICDS project areas and 1.5 million outside |.C.D.S.

projects (1988-89).

iii) Balwadi Feeding Programme The Balwadi Feeding Programme for pre-school children through Balwadies and Day Care Centres was started in 1970-71.

Supplementary nutrition is provided to the extent of 300 calories and 10g.

of protein for 270 days ina year.


About 5045 Balwadis are maintained and aided by 5 national level voluntary organisations viz., Indian Council for Child Weitare, Harijan Sevak Sangh, Bhartiya Adimjati Sevak Sangh, Central Social Welfare Board and Kasturba Gandhi National Memorial Trust to implement the programme.

Grant-in-aid is also provided to voluntary agencies for opening new Baiwadis in backward areas.
The programme covers 2.29 lakh children in the age group of 3-5 years attending Balwadies run by these organisations (1988-89).Minimum number of children ina balwadi is 40 and thestaff per Balwadi is a Balsevika and a helper.

(b) Department of Education i) Mid-Day Meal Programme The Government of India initiated a scheme of providing mid-day meals to primary school children belonging to low socio-economic siatus.

to raise HNutnnoOnal Slatus and increase school enrolment in 1962-63.
After the third Five Year Plan the scheme was included in the State Plans as a centrally aided scneme with cernlral assitance fixed at 40% of the expenditure.

The CARE assited programme was started in 1981 Under this programme 15 States’ Union Territories are presently covered.

The cost of administration, transportation etc.

on this programme ts borne by the State Governments.

Presently CARE provides grains and oils under the programme.
Meals are provided to school children for about 200 days in a year.

Ministry of Food & Civil Supplies Department cf Food i) Nutrition education and extension Mobile Food & Nutrition Extension Units — Nutrition education of the people has been recognised as an important tool for nutrition promotion in the country.

Realising the importance of nutrition education, Mobile Food & Nutrition Extension service was launched as early as in 1964.

Over the years.
Over the years.

34 Mobile Extension Units (MEUs) equipped with mobile van, audio- visual equipment and technically trained personnel have been set up in different parts.of the country to.

impart nutrition education in rural, urban ta and tribal areas.
These MEUs organise live demonstrations supported by lecture-cum-discussions, film and slide shows and exhibitions on various - aspects of food, nutrition & health in collaboration with the concerned Departments of the State Governments, Educational Institutions and Voluntary Organisations.

About 15,000 demonstration programmes cover- ing about 4000 villages are organised annually by these units.
Food & Nutrition Extension Centres — The Department has 33 Food & Nutrition Extension Centres (earlier known as Community Canning & Pres- ervation Centres) in different parts of the country to impart education and training in home scale preservation of fruits and vegetables, and nutrition mainly to the housewives.

These centres (F.N.E.Cs.)


encourage the com- munity to preserve fruits and vegetables during the glut season at the household level by offering two training courses per month in home scale preservation of fruits and vegetables including nutrition and providing processing facilities for fruit and vegetables for domestic consumption on payment of nominal processing charges.
Preparation of Instant Infant Foods from roasted cereals, pulses and oilseeds and Supplementary Foods for children from the family pot is also taught during the training.

About 20,000 women are imparted training annually by these centres.

Integrated Nutrition Education — Nutrition education when implemented with other basic services is perhaps the most cost-effective tool for improv- ing the quality of life and development of a community.
Realising the importance of integrated approach to nutrition education, the Department organises training of grass-root level workers belonging to concerned sec- tors like Agriculture, Health, Women & Child Development, Education, Rural Developmentete.
at village and block level in the form of an Integrated Nutrition Education Camp with a view to impart simple knowledge on food, nutrition & health so that the message of nutrition is conveyed to the community through various grass-root level workers during the course of their respective duties.
The trainers and supervisors of grass-root level workers of concerned sectors are imparted short-term Orientation Tra.....5 Courses for nutrition promotion in collaboration with State Level Training Institutions and Home Science Colleges.

About 32 Integrated Nutrition Education Camps and 40 Orientation Training Courses are organised annually by MEUs and FNECs.

Development of educational and training material is an important com- ponent of the Integrated Nutrition Education Scheme.
Three video filmson nutrition entitted “Feeding infants’,""Conservation of Nutrients” and "Nutri- tional Deficiency Diseases" have been produced recently in different regional languages for education and training purposes.

Slide sets and panels on Integrated Nutrition Education have also been prepared for use during nutrition programmes.
National Nutrition Week — A National Nutrition Week is celebrated in the country from 1st-7th September every year since 1982 in callaboration with the State Governments, Educational Institutions and Voluntary Organisa- tions with a view to create nutrition awareness among the masses and to impart basic messages for nutrition promotion among the people.
Suitable programmes on important aspects of nutrition are also broadcast/telecast on the occasion, Food Processing & Nutrition Centres — The Department has three Food Processing & Nutrition Centres at Balussery (Kerala), Kumarghat (Tripura) 15 and Mahendragarh (Haryana) set up by the designated agencies of the respective State Governments with technical and financial assistance from the Department.

One such centre is being set up at Jaisamund in Udaipur District of Rajasthan.
The objective of these centres is to provide demon- stration/training in the field of home scale preservation of fruits and vegeta- bles, preparation of weaning foods, bakery & confectionary, rice milling, oilseed processing and nutrition education to the rural community.

ii) Food Fortification Programmes The Department has taken up action programmes for fortification and enrichment of food supply for the prevention of specific nutritional defi- ciencies such as Vitamin A, iron etc.
At present, the department is concen- trating its efforts on the following fortification programmes :— a) Fortification of Milk — Fortification of milk with Vitamin A is intended to reduce the incidence of preventable blindness due to Vitamin A deficiency.

Vitamin A content of milk supplied through dairies is reduce due to removal of fat during processing.

In view of this, it has been considered essential to fortify dairy milk with Vitamin A.
The scheme was first introduced in 1980 in Mother Dairy, Delhi.

It has been extended to 37 dairies in the country covering 14 States and 2 Union Territories.

It is being implemented by cooperative dairies of the State Governments/Union Territories at Andhra Pradesh, Haryana, Himachal Pradesh, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Punjab, Rajas- than, Sikkim, Tamil Nadu, Tripura, Uttar Pradesh, West Bengal, Delhi and Pondicherry.
The dairies are eligible for reimbursement of the entire expenditure incurred on fortification for the initial period of 3 years.

There- after the entire cost of fortification is borne by the dairies, At present, about 33 lakh litres of milk is foritified with Vitamin A daily through these dairies.

The.cost of fortification is only 4" paisa per litre of milk.

b) Fortification of Salt — Anaemia due to iron deficiency is a wide-spread health problem in the country.
The fortification of salt with iron is intended to reduce the prevalence of iron deficiency anaemia.

The Department has developed a suitable formula for fortification of salt with iron in collabora- tion with National Institutes with a view to combat such anaemia.

A plant for producing 15,000 MTs of iron fortified salt per annum has been set up at Valinokkam Salt Complex at Ramanathapuram District in collaboration with the Government of Tamil Nadu through its Salt Corporation and with UNICEF assistance.
Another salt fortification plant is being set up at Sam- bar Lake at Jaiour, Rajasthan in collaboration with Hindustan Salts Ltd., Jaipur.

iii) Production of Nutritious Foods & Beverages The Department has undertaken programmes for development and pro- duction of low-cost nutritious foods for meeting the requirements of Sup- plementary Feeding Programmes and vulnerable sections of the popula- tion.
These are :— (a) Miltone — Miltone is a nutritious milk-like beverage based on 50% groundnut protein and 50% animal milk suitably enriched with vitamins and minerals.

Five units are operating at Bangalore, Calcutta, Ranchi, Kanpur 16 and Ahmedabad.

These units have been set up and are being run by the designated agencies of the State Governments with technical and financial assistance from the Department.

About 29 lakh litres of miltone was pro- duced during the year 1988-89 by these units.
(b) RTE Extruded Foods — The Ready-to-Eat (RTE) Extruded Foods pro- duced from cereals and pulses or oilseeds by applying extrusion proces- sing technology and are enriched with vitamins and minerals.

Five RTE plants one each at Dhar in Madhya Pradesh.

Hyderabad in Andhra Pradesh, Jaipur in Rajasthan, Gangtok in Sikkim and Delhi are in operation.

The units at Hyderabad and Jaipur are producing weaning foods also for infants.

The RTE units produced 29187 MTs of RTE extruded foods during the year 1988-89.
(c) Energy Food — Energy food is a biend of cereal and pulse or oilseed flour, fortified with certain vitamins and minerals and sweetened with sugar or jaggery to make it a Ready-to-Eat food supplement suitable for children, expectant and nursing mothers.

Four Energy Food Plants set up at Bel- gaum, Chitradurga, Raichur and Dodaballapura in Karnataka by the kar- nataka State Agro-Corn Products Ltd, produced 17645 MTs of Energy food during the year 1988-89.
One Energy Food Unit is being set up at Jabalpurin Madhya Pradesh.

Indirect Nutrition Programmes — The programmes mentioned so far are the direct intervention programmes in the field of nutrition.

Since it has been scientifically established that malnutrition is a multi-faceted problem and requires a multi-sectoral approach for its control and prevention, all the programmes directed towards the improvement of health of the people are, the indirect nutrition therefore, indirect nutrition programmes.
Some of programmes are Primary Health Care Services, Immunization Programmes, Family Planning Services, Public Food Distribution System, Extension Activities of Krishi Vigyan Kendras and Poverty Alleviation Programmes.
A brief account of these is.as under : Ministry of Health & Family Welfare: i) Primary Health Care Services — The existing interventions of the health sector, some of which are direct nutrition interventions and others having indirect impact have considerable effect on nutritional status of the population, The Central and the State Governments have strengthened their existing programmes for the contro!
of malaria, infectious diseases, tuberculosis, provision of safe water, prevention of food adulteration, immunization and improvement of environmental sanitation during the 7th Five Year Plan, which will have considerable nutritional impact.

Primary Health Care Services provided through a net work of Primary Health Centres and Sub-centres have a great potential for improving the nutrition of the people through its integrated approach and vastly increased coverage.
The number of Primary Health Centres has increased from 725 in the First Plan to 16984 Primary Health Centres and 1,12,103 Sub-Centres in the year 1988- 89.

Some of the services available at the Primary Health Centres are daily General Clinics and weekly Out Patient MCH clinics attended by one of the Medical Officers, In-Patient care and referral to the Distt.
Hospital, 7 At the Sub-Centres, daily General Clinic is attended either by a female Health Worker or a male Health Worker and the services like pre-natal and post-natal care, child health care, immunization, distribution of iron and folic acid and vitamin A, treatment of minor ailments, health education etc.

are provided.
are provided.

The weekly MCH Clinic is attended by the Medical Officer of the Primary Health Centre, and/or the Health Assistant (Female), At the village level, the services of a trained Dai, the Health Worker (Femaie), the Health Worker (Male).

and Health Assistant (Male) are available for providing the health care services at the village level and to refer the cases to PHC, if necessary.
ii) Expanded Programme of Immunization — The Expanded Programme of immunization of the Department of Health, which has been explained in detail in the chapter on Immunization, is expected to break the vicious cycle between mainutrition and infection.

it should be remembered that a condition like measles which is a passing episode in the life of a child in well-to-do families is a great killer among the poor community.

Immunization, thus, is a definite nutrition promoter.
spacing are the two sides of the same coin.

It ili) Family Welfare Programme — \t has long been realised that unless we achieve population stabilisation, our needs would outstrip our production and gross malnutrition would result.
Neediess to say, nutrition programmes and programmes for birth is an accepted fact that without the improvement in the family health, nutrition improvement of the children is difficult and family health greatly depends on the mouths to be fed in the limited resources, The co-relation between nutrition and family size has been well documented.

There have been continuous efforts to integrate family planning services with nutrition and immunization services.
The Department of Family Welfare has jaken up a package programme of small family norm of two children per family coupled with immunizationtoensure mother care and child survival.

Ministry of Food & Civil Supplies a) Department of Food i) Storage of loodgrains & general warehousing — One of the important functions of the Department of Food is to provide storage facilities for maintainance of central reserves of foodgrains and promote scientific storage at all levels.
Storage of foodgrains is one of the important aspects in improving the nutrition of the peoplesince it helps to increase the availability of foodgrains by avoiding its waste through different ways.

The storage plan of the Department aims at providing the capacity required for buffer stock of foodagrains, operational stocks needed for public distribution system and general warehousing.
The Department has also been making efforts te improve the traditional storage practices in vogue at the farm level through its Save Grain Campaign, training, demonstration, publicity etc.
b) Depariment of Civil Supplies Public Food Distribution System — The Public Food Distribution System can be avery powerful weapon to remove the problem of malnutrition from the weakest, economic sectors, These segements have low purchasing power and any measure to provide adequate food and of a reasonable quality to them would greatly enhance their dietary consumption, 18 In India, a food policy has been evolved over the years whose objective broadly is to make available andequate supplies of food at reasonable prices to meet the demand of the people.
In the four decades since the early 40s, a well defined framework of policy has been in existence.

Historically, the distribution system came into being in the country in the form of food rationing, largely in urban areas.

Today, however, out of the 3.5 lakh Fair Price Shops in the country, more than 50% are in the villages, signifying a gradual shift in emphasis that is taking place.
Ministry of Agriculture & Rural Development a) Indian Council of Agricultural Research i) Krishi Vigyan Kendras —Training of farmers and in-service extension functionaries is a critical input for the rapid transfer of agricultural technology and thus increased food production.
The Krishi Vigyan Kendras — Farm institutions Science Centres are the grass-root level vocational training designed for bridging the gap between the available technologies at the one end and their application for increased production at the other.

There are 91 Krishi Vigyan Kendras in the country.


The main objectives of the Kendras are developing and organising non-formal educational programmes by way of farm visits, farmers fair, farm science clubs, radio talks etc., providing practical training facilities of the Kendra to the teachers and the students of vocational agriculture of Higher Secondary Schools, providing added train- ing facilities in the areas of home making and nutrition education for rural community etc.
The specific objectives of each Kendra depends upon the agro-eco system of the area and the needs of the community.

b) Department of Rural Development — Mainutrition is found mostly among the socio-economically deprived population, An important means of reducing the prevalence of malnutrition is to raise the socio-economic status of those who are in the lowest level of that ladder.
Poverty alleviation programmes of the Department of Rural Department have been given considerable emphasis during the successive Five Year Pians.

A brief account of these programmes is as under: National Rural Employment Programme (NREP) ; This programme launched in 1983, is being implemented as a centrally sponsored scheme on a 50 : 50 sharing basis between the Centre and the States.
|t aims at generating 300 to 400 million mandays of employment in the rural areas every year, simultaneously creating durable community assets for strengthening the rural infrastructure.

It also seeks to improve the nutritional status of the rural poor by providing partof the wages imwiint lorm of foodgrains.
Rural Landless Employment Guarantee Programme (RLEGP) : This 100% centrally assisted programme launched in 1983 has the following two objectives : |) To improve: and expand employment opportunities for rural landless in order to provide employment for atleast one member of every landless tabour household upto 100 days every year, and 19 ii) Creation of durable assets for strengthening the rural infrastruciwre which will lead to rapid growth, The implementation of the RLEGP Is entrusted to the State/Union Territory Governments.
Construction of rural link roads, fand development, social forestry, minorirrigation works etc.

can be taken up under this programme.

The wages are fixed keeping in view that an unskilled labourer is able to get wages equivalent to the prescribed minimum agricultural wage for unskilled workers.
The wages are required to be paid partly in food grains and partly in cash, Integrated Rural Development Programme (IRDP) : The Integrated Rural Development Programme which was introduced in the Sixth Plan, aims at income generation for the weaker section.
The activities through which the identified poor families would achieve higher incomes, cover agriculture including animal husbandry, horticulture and fisheries, small and cottage industries, traditional handicrafts and practically every viable economic activity with a potential for providing employment and higher incomes to the beneficiaries.
The Programme is financed by a combination of subsidies provided by the State and loans advanced by banking institutions both co- operative and commercial, The IRDP in now under implementation in every part of India's rural areas.

The dDiock has been identified as the smallest viable unit for local level planning.
On an average 600 families are being assisted under this programme in a block if.a year, During the first four years (upto Dec., 1988) of the Seventh Plan, over 1,34 crore families have been assisted.

Training of Rural Youth for Self Employment (TRYSEM): This programme is an essential component of the IRDP.
After identifying training needs in the blocks, potential beneficiaries are selected for suitable training which is imparted in the existing institutions by devising appropriate courses ina variety of trades and skills.

Ina decentralised and informal manner training is also imparted to a number of rural youth by attaching them to master craftsmen in the rural areas, Both trainees and trainers are provided incentives Industrial Training Institutes, for making the programme attractive.
Polytechnics, Agricultural Colleges and a number of other educational and research Institutions are involved in this programme, Once the training programme is completed, the trainees are encouraged to start enterprises of their own through the assistance provided under the Integrated Rural Development Programme.
Nutrition Education, Training & Research Ignorance and lack of knowledge about nutritional needs, widely prevalent in the country, emphasized the importance of nutrition edcuation and training at all levels.

Various types of orientation courses are now available for all categories of personnel implementing the programmes, Nutrition education of the community, though a stupendous task for a country like India, is being attempted through ali available media and channels.
In addition, courses leading to certificates, diplomas and degrees in public health nutrition are being conducted by certain institutes in the country, Research studies in the field of nutrition with emphasis on applied aspects are also being encouraged in suitable centres.

20 Chapter-4 SOME BASIC FACTS ABOUT FOOD Food provides nutrients which are needed for giving energy, body build- ing, repair of tissues, formation of enzymes etc.

Foods vary in their composition.


The availability of nutrients differ from food to food.

In order to derive balanced diets, nutrients have to be provided In adequate and pruper propurtions To understand the basics of food and nutrition, the information in this chapter is presented under the following sub-heads — What is food ?

— Why do we eat ?

— Different foods have different functions — Functions of nutrients & their sources.

— What should we eat ?

— {s there any dietary pattern ?


— Are animal foods essential ?

— How to improve diet at low cost ?

— When are growth promoting foods most important ?

— Why should we pay special attention to the feeding of infants & young children ?

What is food 7?

Everything that we normally eat and drink can be called food.

Things consumeu as food difter from one country to another and sometimes even within different regions of one country.
The things people regard as foodin different parts of the world have been selected by trial and error over hundreds of years.

A field worker must know what types of food are con- sumed in her area, what items of food people like, and what foods people do not eat even though they are cheap and abundant The field worker should also know why people do not eat certain types of foods.

Why do we eat ?
Why do we eat ?

Life cannot exist without food and it is for this reason that every living organism tries hard to obtain it's food requirements.

Human beings do not possess the capacity to manufacture food from simple chemicals like plants, and hence, they depend on piant life or other animals for obtaining the food they need.

We eat whenever we are hungry.

Satisfying hunger is just one function of food.

However, there are other important functions that we usually do not think about when we eat.
Basically, foods have three important functions for the human body ; to give energy for all types of activity, to help the body to.grow in size and to protect the body from diseases.

21 Functions of food To Provide Energy To Sustain Growth, To Give Protection from Diseases.
Different foods have different functions Food stuffs may be broadly classified as cereals, pulses, nuts and oilseeds, fruits, vegetables, milk and milk products and flesh foods, These foods contain chemical substances known as nutrients and It is for obtaining these nutrients, which perform various functions in the body, that food is consumed daily by any living organism.

The nutrients include proteins, fats, carbohydrates, vitamins and mineral salts.
These can be divided into three categories according to their functions : energy-giving nutrients, body-building nutrients and protective nutrients.

Most foods contain a mixture of the three categories of nutrients, but usually in one type of food one of the categories is present in a larger amount than the other two, and the function of that nutrient becomes the main function of that food.
For example, cereals such as rice and wheat have all three categories of nutrients, but the energy-giving nutrients are the most abundant, and therefore giving energy is the main function of cereals.

However, if a cereal is taken in large amounts, it can also supply sufficient nutrients for promoting growth.
For example, in developing countries, wheat/rice not only supplies energy, but a major part of the body’s need for body-building nutrients, Commonly eaten foods can be broadly divided into three groups according to these three functions : Energy-giving foods — For essential functions such as respiration, blood circulation, digestion, absorption and excretion, maintenance of body temperature and other normal physical work, body requires energy.
The foods nich in energy—carbohydrates and fats —are classified as energy giving foods.

Energy giving foods are : Cereals like wheat, rice, maize; Millets like bajra, jower, ragi etc; Fats and Oils; Strachy vegetables and potatoes, sweet potato, Cassava; Sugar, molasses and honey, Growth-promoting foods — Human body is made up of cells mass.

Proteins are primarily responsible for generation, development and maintenance of the body cells — tissues.
Therefore, the foods rich in protein are classified as growth promoting foods.

Children need proteins to grow,expectant mothers for the development of baby in the womb and nursing mothers need protein to produce sufficient milk for the growth and survival of a new born baby.

Growth promoting foods are : Most foods of animal origine.g.

milk, eggs, fish and meat.

Some foods of vegetable origin e.g.

pulses, peas, beans and nuts.


Protective foods — For vital processes of life, and formation and development of bones and teeth, some organic substances known as vitamins and minerals are required, A large number of minerais are present in a human body.

Bones and teeth are made up mainly of the minerals.

Foods rich in vitamins and minerals are Known as protective foods.

These foods, though needed in small quantities, are very essential.
The deficiency of these vitamins and minerals can cause mal-functioning in the body resulting in diseases, Protective foods are : Vegetables especially the green leafy type.

Yellow and orange coloured fruits and vegetables \ike carrots, papaya, mango, tomato, 22 orange and Fruits with sour juice (citrous fruits) like orange, lime, lemon, grape-fruit etc.
Functions of nutrients & their sources 7 Different nutrients have specific functions to perform in our body and different foods are rich in different nutrients.

The functions of various nutrients and their rich sources have, therefore, been summarised in Table-!

What should we eat ?


Man has a number of foods to choose from to make up his diet and since all the foods do not have the same nutritive value, the health of a person depends on the type, quantity and quality of foods he consumes to satisfy his hunger.

There is no'such thing as an ideal diet.

But to live a healthy life we must eat a mixture of foods, some that give energy, some that promote growth, and some that protect from disease.
(In the case of adults, growth promoting foods are needed for the repair of the daily wear and tear of the body).

Thus, we should not be guided only by our taste.

The quantity of each type of food and combinations can of course vary.

Quite often children are fond of eating sweets and reject other foods which are good for them.

This is harmful for the body and teeth.

Is there any dietary pattern ?

There is a dietary pattern, especially in the case of adults.
Men and women living in different countries and in different environments remain healthy on diets that differ widely.

In spite of these differences, there is acommon pattern among adult diets in developing countries even though owing to poverty the choice of foods is limited.

The pattern is as follows : — The main part of the diet consists of cereals such as rice, wheat, maize or millet or foods prepared from these cereals.

Cereals are normally the cheapest part of the diet.
In some parts of the world plantain, cassava, or potatoes form the main part of the diet instead of cereals.

— Supplementary foods Include pulses, beans and peas.

These are always eaten with the cereals.

They give variety to the diet and make the cereals more palatable.
Similarly, vegetables are also eaten with cereals and pulses to increase ‘palatability and variety Thus, in most developing countries the majority of the people live largely on diets made up of cereals, beans or pulses, and some vegetables, However, some other types of food are also consumed in lesser quantities, These are touds of animal origin.

They are the most expensive items of the diet, and include meat, fish, milk and milk products.
Fats and oils, which are mostly used for cooking foods, greatly improve the taste of food.

Since foods of animal origin are generally expensive, only rich people can afford to eat them regularly.

Animal fats are more expensive than vegetable oils, With improvement in economic status, the quantity of fats and oils in the diet increases.

A daily diet should be a mixture of : — Cereais — Pulses, beans or peas 23 — Vegetables, preteraply of the green leafy type.

Animal foods are a welcome addition.


Are animal foods essential ?

Animal foods are not essential but they are desirable.

As mentioned earlier, animal foods are very useful for promoting growth in children.

In adults, growth- promoting foods are needed for the repair of the daily wear and tear of the body.

In fact, even when the body is not growing, some wear and tear does take place and growth-promoting foods are needed for repair.

Protein is the nutrient specially suitable for this function.
The protein found in all animal foods is of high quality, and it is present in large amounts.

However, vegetable foods like peas, beans.

pulses and nuts also contain large amounts of protein, and therefore can promote growth as well.

But the protein in such vegetable foods is of a lower quality.
However, when two or more protein-containing vegetable foods are mixed, the protein in the food mixture is almost of the same quality as that found in animal foods.A field worker should know the types of food mixtures that give such superior combinations.

The following are two good combinations .

— Double mix: Cereals plus pulses — e.g., rice and pulses, corn and beans, and wheat and pulses or beans or peas.

— Triple mix .
— Triple mix .

Cereals plus pulses or beans, plus green leafy vegetables, MIXTURE OF SUITABLE VEGETABLE FOODS ARE ALMOST AS GOOD AS ANIMAL FOODS FOR GROWTH PROMOTION, \f animal foods are within the family budget and are normally consumed, then the addition of even asmall quantity of animal food to a vegetable food mixture greatly improves the growth-promoting effect.

This is specially important in the feeding of infants and young children.

ANIMAL FOODS ARE NOT ESSENTIAL.


THEY ARE DESIRABLE, ESPECIALLY FOR INFANTS AND YOUNG CHILDREN.

Mother's milk is an excellent addition to vegetable food mixture in promoting growth of infants and very young children, Thatis why the advice to all mothers should be to continue breast-feeding as long as possible, because even a small quanity of mother’s milk can greatly improve the quality of vegetable food supplements the infant or the young child is getting.
This is more important if the mother cannot afford to give other types of milk (e.g.

cow's milk) to infant or child: How to improve diet at low cost ?

The diets consumed by a majority of the population in India are highly cereai based.

The cereal forms almost the bulk of their diet and constitutes the major source, if not the only source, of nutrients, particularly in the case of people belonging to lower socio-economic groups.

It is these diets that need improvement.


If means allowed, quantities of food stuffs required for well balanced diets (as given in Annexure-II!)

would be the best substitute but it is also a fact that items like milk, fruits and flesh foods are expensive and beyond the means of acammon man.

However, attempts to Improve the diets are likely to be limited by the income of the family and if the ideal is not possible to be attained whatever is economically feasible, must be attempted.
A wide choice of inexpensive foodstuffs is available in the country and a judicious use of these food stuffs will greatly heip in correcting dietary inadequacies.

24 The broad lines on which : for groups of persons can be improved are | a) Introduction of a second cereal or mixed cereal diet.

Substitution.of even a part of the staple cereal viz.

rice or wheat by millets like ragi or bajra will provide a diet with better nutritive value at practically no extra cost.
b) Increased intake of pulses wherever feasible.

c) Increased use of green leafy vegetables in the diet, d) Introduction of cheap flesh foods, 2-3 times:a week, if possible It is desirable that children consume daily at least 250 ml.

of milk.

If meansdo not permit the intake of this amount of wholemilk, butter milk or skimmed milk reconstituted from skimmed milk powder which is considerably cheaper, may be consumed.

Even a little milk is better than none.


If the cereal consumed Is milled rice, an improvement in the nutritive value of the diet can be brought about by wholly or partially substituting the milled rice by hand pounded rice or par-boiled rice, whole wheat or one of the millets particularly ragi.

The milled rice eater needs more protective foods such as pulses.

milk, qreen leafy vegetables, fruits etc.

than whole wheat or ragi eater _ Pulses are rich source of proteins and some of the B Vitamins.
Even a small quantity of pulses will considerably improve the nutritive value of a diet largely composed of cereals.

Sprouted pulses, when consumed also provide Vitamin C Soyabean is also a rich source of protein and fat and comparatively cheaper When are growth promoting foods most important ?

Infants and young children grow very rapidly.

A healthy new-born baby doubles his weight in 5 months.

This growth is the result of increase in the amount of soft tissue (muscle, skin etc.)
and in the size of bones, which make up the frame of the body.

Thus, children need foods that promote the growth af both soft tissues and bones Proteins are nutrients that promote the growth of soft tissues.

Minerals (another type of nutrient) promote the growth of bones.

Foods for young children should contain both these nutrients, MILK 1S EXCELLENT FOR THE GROWTH OF MUSCLES AND BONES IN INFANTS AND YOUNG CHILDREN — SREAST MILK IS BEST.
The following is a list of some categories of foods that are excellent for the growth of infants and young children ; — Pulses such as lentils and grams (green gram, black gram etc.)

— Peas and beans — Nuts (e.9.

groundnuts) — Vegetables (especially the green leafy type) — Milk and milk products — Other foods of animal origin (¢.g.

meat, fish and eggs).

During pregnancy a woman's body grows very rapidly.

This growth takes place not only inside the womb, but also in her own body.
In the course of only 280 days of pregnancy, a tiny fertilized egg cell grows into a fully formed baby of 2500 grams or more.

The raw material needed for this tremendous growth comes from the diet of the mother.

If the mcther lives on a poor diet during pregnancy, her baby will be lighter and smaller (low-birth-weight infant).

Such babies can be regarded as malnourished.

They are vulnerable to not only nutritional deficiencies but alsc infectious diseases.
DIETARY CARE IN PREGANGY IS THE STARTING POINT FOR GOOD INFANT NUTRITION.

25 Breast-feeding mothers also need extra growth-promoting foods.

Human milk is produced in the breasts of the mother from raw materials which come from her diet, In order to produce enough milk of good quality, a mother must have a diet consisting of adequate amounts of cereals, pulses, beans, vegeta- bles; oils.and, if possible, animal foods.
Why should we pay special attention to the feeding of infants and young children As ment oned earlier infants and young children grow very rapidly.

There is growth of soft tissues and also of the bones, for both of which special care has te be taken to include growth-promoting foods in the daily diet.
How- ever, it is important to pay special attention to the feeding of infants and young children for other reasons : a) Although infants and young children are small-and appear to be inactive, they are in fact very active.

Their need for energy in relation to their body size is much greater than that of an adult.

This fact is usually forgotten.

Special care is necessary to include in the diet energy-giving foods like cereals, fats and oils, and sugar.

Giving growth-promoting foods alone is hot enough.


b) Infants and smail children have no or few teeth.

This means that they cannot eat solid or hard foods that require chewing.

Therefore, only liquid or semi-solid foods should be selectéd for them, If solid foods have to be given, they should be prepared in such a way that they become soft, Some foods do not become soft even after much cooking (e.g.

certain tough fibrous vegetables); these should be avoided even though they are nutritious.
Soft, cooked cereals and pulses, boiled mashed potatoes, and cooked, mashed, and sieved vegetables are very suitable preparations to start with.

Do not forget to adda little oil or fat in the preparation.

c) Infants and young children have small stomachs and therefore they can eat only asmail quantity of food at each feed.

Adults ‘on the other hand eat only two or three big meals a day.

In the feeding of young children, the golden rule is to give small and frequent feeds.
Remember : — Infants and young children are very active and need a — They cannot chew properly.

— They can eat only a small quantity of food at each feed.

lot of energy.

Therefore, give them; — Both growth-promoting and energy-rich foods.

— Foods of soft, semi-solid consistency.

— Small but frequent feeds.

FUNCTIONS OF NUTRIENTS AND THEIR SOURCES Table-1 Nutrient Functions Sources 1.

Projein Building and maintenance of all body tissues.
Formation of = Meat, fish, eggs, milk, channa, cheese, curds, 26 2 Fat Substances essential to body functions, such as enzyme, anti-bodies, harmones etc.

Regulation of body processes.

ice-cream, pulses, dried peas and beans, soya- bean, nuts, groundnuts and cereals.

Concentrated source of energy, Provide Essential Fatty Acids to the body.

Carriers of Vitamin A, D, E and K. Protection of the body.

Butter, ghee, vanaspati, vegetable oil, oilseeds and nuts, soyabean and avocado pear.

3.
3.

Carbohydrate Main source of energy for the Cereal grains, millets, body functions.

pulses and legumes, roots & tubers such as Sparing protein for its primary purpase.

potatoes, sweet Providing fibre/roughage to aid potatoes, yam, tapioca in normal peristaltic movemer's.

etc.

; sugar and jaggery, 4.

Vitamin A Essential for healthy eyes and skin, Promotes growth.

Maintains integrity of mucosal epithelium.


Maintains visual acuity in dim light, processed foods such as noodles, jams, jellies, pastries, breads, cakes and candies.

Leafy vegetables, fruits, condiments & Spices are rich in fibre.

Fish liver oils, liver, butter, ghee, cream, whole milk, whole milk curd, cheese, egg yolk, green leafy vegetables, yellow vegetables (pumpkin, carrots) yellow fruits (Papaya, mango), Fortified fats.

5.

Thiamine (Vitamin By) 6.


Riboflavin (Vitamin Bo) Part of enzyme system concerned Unmilled cereals, wheat with the proper utilisation of carbohydrates in the body.

Maintenance of normal gastro- intestinal tone and motility, normal heart action and nervous stability.

germ, whole wheat, parboiled nce, pulses & legumes, soyabean, nuts particularly groundnuts, dried yeast, liver, glandular organs & pork.
Milk & milk products Constituent of enzyme system — essential link in the metabolism of (including skimmed protein and carbohydrates, Maintenance of normal skin tone, digestion and vision.

milk, butter milk, curds, cheese and whey), eggs, liver, kidney, heart, meats, green leafy vegetables and dried yeast, शा .

Nicotinic Acid Essential component of enzymes Whole grain cereals, (Niacin) - Vitamin Bg for effective release of energy in the body.
Maintenance of normal function- ing of gastrointestinal tract, skin and nervous system.

pulses, nuts particularly groundnuts, liver, meat and yeast.

Constituent of enzymes which participate in amino acid meta- _ kidney, meat, whole bolism.

Participates in metabolism of un- vegetables.

saturated fatty acids.

Wheat germ, liver, grain cereals and Vitamin Byo Essential for maturation of red blood cells in bone marrow.

Involved in synthesis of nucleic acid.

== Liver, kidney, milk, cheese, muscie meats.


10, Folic acid Necessary for blood regeneration.

Liver, kidney, yeast, Participates in nucleoprotein meta deep green leafy vege- bolism.

tables and pulses.

11, Ascorbic acid Forms & maintains intercellular (Vitamin C) substance.

Required for healthy gums and body's resistance.

Fresh fruits particularly citrus fruits, guava, tomatoes, amla, raw vegetables, leafy vegetables and sprouted pulses.

12, Vitamin 0 13.
12, Vitamin 0 13.

Calcium 14 Iron Promotes normal skeletal & tooth Fish liver oils, expo- development.

sure to sunlight, liver, Regulates absorption & anchorage egg yolk, butter, ghee of calcium, phosphorous.

and milk.

Builds bones and teeth, Blood coagulation, Normal heart rhythm.

Muscle contraction.

Nerve irritability.

Aids in use of iron.


Activation of some enzymes: Milk (including skimmed milk & butter milk), curds, channa, cheese, small fish, green leafy vegetables, tapioca, cereals (exclud- ing rice), millets, ragi, gingelly seeds.

Constituent of haemoglobin whichLean.

red meats, liver, egg yolk, whole grain carries oxygen to the tissues.

cereals and pulses such Constituent of bone: as whole wheat, bajra, bengalgram, green gram, soyabean; green leafy vegetables, nuts and oilseeds.
jaggery, dates, sprouted pulses.

28 Chapter-5 CARE OF THE PREGNANT WOMAN Motherhood is a bliss.

To give birth to.a healthy child is the ambition of every woman.

In order to achieve this ambition, a pregnant woman should be fully aware of thé following aspects : — Importance of good diet before pregnancy — Dependence of foetus on mother for nourishment.

— Diet during pregnancy.

— Ideal weight gain during pregnancy.

— Il effects of mainutrition during pregnancy.

— Unhealthy taboos.
— Unhealthy taboos.

— Need for prenatal, natal and postnatal care.

— Immunization of pregnant woman against tetanus.

— Encouraging the use of maternal and child care services, supplementary feeding at anganwadis etc.

Importance of good diet before pregnancy : Itis important that a woman maintains good health during pregnancy in order to deliver a healthy baby.

The health of a woman before pregnancy is equally important in determining the outcome of pregnancy.
A well nourished woman has a better chance of having a healthy baby than a poorly fed woman, A healthy woman has an advantage of starting her pregnancy with sufficient stores of nutrients jn her body.

If a woman is already mal-nourished, it will not only be difficult for her to deliver a healthy baby but it may worsen her heaith further.

It is, therefore, important that girls’ nutrition isnot neglected Rather, it requries special care during adolescence and thereatter so as to make them healthy women.
Dependence of foetus on mother for nourishment : Tne growing infant in the womb — foetus, solely depends on the mother for nourishment.

Its nutritional needs gradually increase as pregnancy progresses.

The foetus weighs about 15 g. around the 12th week and develops into a fully grown baby of about 3200 g. by the 40th week, The mother has to supply all the nutrients needed for this enormous growth and development to the foetus through her blood stream.
29 The mother must, therefore, know that within her is a growing baby depending entirely on her for its food and that she has to provide for herself and the growing baby right through the pregnancy.

In case she does not provide for both, the baby willsomehow manage to get what it needs from its mother which will come from her body stores and it is the mother who will suffer more.
Diet during pregnancy : During pregnancy extra energy is needed for the growth of the foetus, the placenta and associated maternal tissues (such as breasts) and for the increased energy expenditure involved in the movements of the heavier mother.

The mother's basal metabolism also rises.

These changes involve a total additional requirement for a pregnancy lasting 9 months, of the order of 80,000 calories.
The extra calorie needs imposed by pregnancy can, however, be covered in two ways; either by increased food intake or by reduced physical activities, The-extent to which each of these two factors contribute to ensuring energy balance during pregnancy is determined largely by social and economic factors.
Thus a poor woman who already has several small children to care for will need extra food, whereas, a well-to-do woman with few domestic responsi- bilities may well achieve energy balance by cutting down physical activity, and, therefore, would not require additional calories from the food.

With many women, both a reduction in activity and a modest increase in food intake are likely to take place.
It is recommended by experts that a pregnant woman needs to have 300 calories and 15 g. of protein from food daily over and above her normal requirements.

The additional energy can be obtained by increasing the amount of cereals, fats and oils and sugar and jaggery in the diet.

The extra protein requirement for the growth of foetus can be met by increasing the amount of pulses and milk in the diet.
If animal foods such as eggs, meat or fish are culturally acceptable and can be afforded, the same should be included in the diet of a pregnant woman, Iron and folic acid (a vitamin of the B Complex group) are required for blood formation, while calcium for building the bones.

The extra requirements of minerals & vitamins, namely, iron, calcium and folic acid, vitamin ‘A’, etc, can be met by regularly consuming green leafy vegetables.

Vitamin ‘A’ is necessary for the good eye-sight of the baby.
In fact, iron and Vitamin ‘A’ can be stored in the baby's body before birth, Since the diet of the young infant, namely the breast milk is deficient in iron, it is all the more necessary to provide sufficient iron to the mother so as to build up good iron store for the baby.

A pregnant woman, therefore, needs more food and a greater variety of food.

More food is the first and most important thing.

She should eat 1/4th more food than she was eating before she became pregnant (25% extra).
A pregnant woman must Consume a diet containing extra amounts of mixed cereals, pulses, green leafy vegetables, milk & milk products and seasonal fruits.
An egg a day, if acceptable and can be afforded, should be included in her diet, The following diet will supply all the nutrients needed by a pregnant woman for her own health and for the good growth and development of the infant-in-womb : Balanced diet for pregnant woman doing sedentary work Cereals Pulses 445 g. 55 g. 30 Leafy vegetables Other vegetables Roots & Tubers Milk Oil and Fat Sugar or Jaggery 100 9.

40 5.

50 6, 200 4.

20 g. 30 4.


The amount of milk indicated in the table is the minimum requirement.

She should consume two glasses of milk daily, if it can be afforded.

Milk provides good auality of protein and calcium.

Part of the cereal can be replaced by ragi, so.

as to Supply more calcium-Anyavailable seasonal fruit should be eatendaily.

Besides meeting the nutritional needs, a diet must take care of possible problems of pregnancy which are due to faulty diet of a pregnant woman.
The following suggestions may be helpful for the diet of a pregnant woman : (i) Excessively spicy food should be avoided as it may lead to a ‘Heart Burn’ (a burning sensation in the stomach & gullet); 11) Foods must be simple, nourishing and easy to digest; (iii) Bowels may become constipated during pregnancy, Drinking plenty of water and taking salad (raw vegetables like carrot, radish, cucumber, tomato, etc.}
in each meal will heip prevent constipation; (iv) During the initial stage of pregnancy, nausea and vomiting are common.

(v) There is no necessity to force the mother to eat at such times; A pregnant woman should consume small amounts of food at frequent intervals in order to avoid the complaint of ‘fullness’ of the stomach.

ideal weight gain during pregnancy : A healthy woman of normal weight before pregnancy may be expected to gain 10-12 kgs.
of weight during gestation and an increase of this order gives an indication that the caloric intake is adequate.

Sudden increases in weight during pregnancy are often due to pathological causes which require medical attention.

For these reasons, the regular recording of weight throughout preg- nancy is desirable.

A pregnant woman has to store enough fat and several other nutrients in her body to meet her own needs and those of the infant immediately after birth.
If the mother does not consume adequate nutritious die}, she may gain just 5-6 kgs.

Ill effects of mai-nutrition during pregnancy : If a pregnant womans diet is not nutritionally adequate, she cannot transfer the required nutrients to the foetus, Foetus then tries to draw its nourishment from mother’s body reserves.

This affects the mother's health.

If she is already mai-nourished, then both the mother and the infant will be affected.
Some of the effects of mal-nutrition during pregnancy are ; (i) The outcome of pregnancy may not be fruitful.

Abortion can take place.

Or the infant may beborn before full term.

Infant may be small in size with less than 2,500 g, of body weight.

Infants with such low birth weights, may not have enogh nutrients stores.

They may easily become mai-nourished and may have poor resistance to diseases.

(ii) A poorly nourished pregnant woman cannot withstand the stress &strain of pregnancy and child birth.
If well nourished, she has more chances of successfully going through her pregnancy and childbirth.

A mainourished pregnant woman will be generally thin or wasted.

Her arms and legs will be 31 (ii) very thin, and there may be loose folds of skin over her upper arms, chest or abdomen.

These signs indicate that she has no stores of fat under her skin.

A mal-nourhsed pregnant woman should be encouraged to eat as much food as can be afforded.
If food supplements are available under a feeding programme, she should receive these as priority.

If the diet of the pregnant woman lacks in iron, she may suffer from ‘Anaemia’.

This isa common nutritional problem in pregnancy.

An anaemic woman will not have enough red colour in her blood.

The inner side of the lips or the lower eyelids will be pale, light pink or white instead of red.
She will easily become breathless after little exersion, Her face and feet may alsobecome swollen/if she is severely anasmic.Such severe cases should be referred to the nearest health centre.

Anaemia in pregnancy can be prevented by a good mixed diet, like the one described earlier, The main nutrient required in treatment of anaemia is iron.

Since it is difficult to increase the intake of iron with diet alone, iron tablets are supplied by health workers to all the pregnant women.
One iron tablet should be taken everyday with food atleast from the 3rd or 4th month onwards.

(Iron Tablets may Cause biack stools which need not bother the pregnant woman).

Unhealthy taboos : There are many beliefs and practices about the pregnancy in different cultures: Some of these concern.-the relationship between what the mother eats and how the child will develop.

Certain foods are believed to producea child of difterent characteristics e.g.
brave or cowardly,|beautiful or ugly, There is no scientific basis for these beliefs.

Some mothers believe that if they eat too much, the baby will grow too big.

They think that a big baby will cause a difficult delivery.

This is not true and itis a harmful belief, Even if a mother eats a lot, the baby cannot grow larger than acertain size.

Cn the country, if a mother eats well, both she and her baby will be strong and healthy at the time of delivery.
There are beliefs that foods like egg, meat and papaya are ‘Hot’ foods and can cause abortion.

It is believed by.some that since banana tree flowers only once in its life time, eating banana during pregnancy would lead to a ‘one child’ sterility.

All these beliefs have no scientific basis.

It is, therefore, very important to discourage all unhealthy taboos prevalent in the community There are some healthy traditional beliefs also.
In some cultures, preg- nant women are given special foods, These foods are often nutritious.

These are good practices and must be encouraged, Need for prenatal, natal and post natal care : Itis important that a mother maintains good health during her pregnancy in order that she may deliver a healthy baby, She must have regular health check ups, specially with respect to weight, blood pressure and urine.

Itis also important that she should receive competent care during her labour and that after delivery.
She and her baby should be followed up to ensure that they progress normally.

The following points should, therefore, be emphasised about the need for pre-natal (during pregnancy), natal (during delivery) and post natal (after delivery) care; 32 1.

Regular prenatal care given by the Health Worker (Female) or trained dat is important for the health of both the mother and her unborn baby.
Prenatal care ensures the following - (a) The health problems of the woman are treated or she is referred to hospital as early as possible.

(b) tetanus toxoid is given well before the expected date of delivery.

(6) Iron and folic acid tablets are given to those who are anaemic.

(9) The woman receives the necessary information about how to look after herself during pregnancy and how to prepare for delivery.

2.

Proper careduring labour ensures the following : (a) Prevention of infection.
(b) Prevention of complications caused by improper handling during delivery, (c) Early referral when complications arise.

3.

During the first week after delivery the mother and baby should be seen by the Heaith Worker (Female) or the trained dai, and subsequently, both mother and child should attend regularly the MCH clinic at the subcentre.
If necessary, the mother or baby can be referred in goad time 4, Regular postnatal care ensures the follawing (a) Health problems in the mother can be identified and treated early (b) Health problems in the baby can be identified and treated early (c) (d) Iron and folic acid can be given if necessary.

(@) The baby can be given the necessary immunization (f) The mother can be given family planning advice.

(g) The mother can be advised about infant care and proper feeding.
immunization of the pregnant woman against Tetanus : The pregnant woman must be advised to get herself immunized against tetanus.

Tetanus germs are commonly found in rural areas because of the close association between animal manure and human habitation.

The use of unclean instruments during home delivery and the improper care of the cord stump after it has been cut can cause tetanus in the new-born.

This is usually fatal.


The disease can be avoided by the following measures (a) Immunization of the pregnant woman with tetanus toxoid given between the 5th and 8th months of pregnancy In two doses at an interval of 2-3 weeks.

(b) lfforsome reason, tetanus toxoid has not been given during pregnancy.
iis very important that special precautions are taken to use sterile msttu ments and dressings in cutting and medicating the baby’s cord Encouraging the use of maternal and child care services, supplementary feed- ing at Anganwadies etc : The pregnant woman should be educated about the availability of maternal and child care service, provision of food supplements at anganwadies and encouraged to utilise these facilities.
In fact the whole community should be informed about the various services which are available for mothers and child« ren in the village at the subcentres, Primary Heaith Centre, Anganwadi centre etc.

Every opportunity should be taken toencourage the community members to make use of these facilities so as to promote maternal and child heaith.
33 Chapter-6 CARE OF THE NURSING MOTHER Breast-feeding is best, In order to enable a nursing mother to breast-feed her baby successfully, Care about her diet and other factors influencing lactation is essential.

Education of the mothers should, therefore.

be on the following lines — Importance of good diet during lactation.

— Breast-milk production.

— Diet during lactation.

— Care of other factors influencing lactation.


34 — Encouraging the use of maternal.and child care services, supplementary feeding at anganwadis ete.

importance of Good Diet during Lactation : While the baby is‘still in the womb, all the essential substances needed for growth are carried to it by the mother’s blood stream.

After the cofinement the blood supply to the breasts is increased so that the baby can continue to be nourished, this time with his mother’s milk.
Thisis undoubtedly the perfect food for baby and will supply all his needs for the first few months until he is ready for the gradual introduction of infant foods.

The mother who has taken a proper diet during preqnancy has paved the way for successful breast-feeding.

Once baby is happily established on the breast, the mother’s diet is just as important as it was before the birth.
Since the new born continues to depend on the mother for its nourishment even after the birth, it is essential that a nursing mother continues to take sufficient amounts of nourishing, wholesome toods soas to provide a good supply of breast milk to the baby to ensure his proper health.

Breast milk provides all the nutrients needed by the new born for the first 4 to 6 months.

Compared te pregnancy, breast-feeding imposes greater stress on the mother.
This is because the infant is older and is grawing rapidly, thus needing more nourishment than the infant-in-womb.

Milk secretion begins when the baby is born and the mother continues to supply nutrients to the baby through breast-feeding.

Nursing mother, therefore, have to eat well and eat the right kind of foods so that the breast-milk can meet the nutritional needs of the baby.

Breast Milk Production : The mother produces about 450-650 mi.
of breast-milk per day during the first 6 months of lactation.

The nutrients present in this amount of milk and the nutrients required for producing this milk have to come from the mother.

The successful lactation, therefore, depends on the diet consumed by a lactating mother.

If the diet of the lactating mother is adequate, the additional nutrients consumed can be diverted for the formation of milk.
But if she does not consume nutritious diet in required quantities, her own body stores will be used up thus affecting her health and nutritional status.

This is the reason that even a poor mother with unsatisfactory diet can produce the same quantity of milk.
But this is done at the cost of her own health, Besides the quality of milk produced by the woman whois not taking nutritious diet willbe poor in respect of the vitamins content of the breast-milk as compared to the breast-milk of a woman who is consuming nutritious diet because the quanti- ties of vitamins present in the milk depend on the diet of the mother and cannot come from the mother’s body stores.
Women from lower income groups who nurse their babies at breast almost till the next infant arrives without consuming extra food, and who have a number of pregnancies, tend to suffer from osteomalacia, osteoporosis etc, in tater life in which the bones.

are depleted of their calcium content and become fragile.

A nursing mother’s diet ought to be more nutritious than when she was not nursing.

In practice this is not so.


There are many beliefs and taboos as in the case during pregnancy which restrict the diet of a lactating mother.

As a result, there is a limitation in choice of foods thereby reducing the nutritive value of the 35 diet.

One of the common taboos.

is not to consume cold foods (curd, \ce- creams, cold drinks etc.)

and gas producing foods (such as black gram dal, kabull chana, cauliflower, cabbage etc.)

as they tend to harm the breast-fed infant.


There is no scientific basis for such a belief.

It is, therefore, essential to educate the community about nutritional importance of these foods and advise them not to follow such food beliefs blindly.

There are certain foods which are known to increase milk production such as cumin seeds, ajwain, garlic etc.
While no harm may be done by the consumption of these substances, there is no scientific evidence confirming to their effect on the breast-milk production, Diet during Lactation : A well balanced diet is needed for milk:production, The depletion of nutrients of the mother through milk has to be made good through food intake in order to protect the health of the mother.

A nursing mother requires a diet which is rich in energy, protein, calcium, iron, vitamin ‘A’ and vitamin ‘C’.
A nursing mother needs mcre energy so as to be able to produce enough quantity of milk.

A variety of cereals should be consumed by her in adequate quantities to provide enough energy and other nutrients.

A nursing mother requires more proteins because high quality proteins have to be synthesised by her for producing milk.

inclusion of pulses in both the major meats of the day in some way or the other will provide a good amount of proteins.
If animal foods such as meat, eggs or fish are culturally acceptable and can be afforded, they would be helpful in provid- ing good quality protein.

She must consume atleast the amount of milk indi- cated in the balanced diet daily.

It would, however, be desirable if she could consume atleast 2 glasses of milk every day.

Scientists have shown that the quantity of breast-milk produced is directly dependent on the intake of proteins by @ nursing mother.
Catcium, iron, vitamin ‘A’ and vitamin ‘c’ are other nutrients which need tobe supplemented during lactation.
The consumption of green leafy vegetable preparation atleast once daily and inclusion of some seasonal fruit in the daily diet like guava, banana, papaya etc., is sufficient to take care of the additional requirements of these nutrients in a lactating mother's diet As in the case of pregnant woman, nursing mothers need to take only additional amounts of the same foods that are normally consumed, Intake of green leafy vegetables, milk, pulses and cereals should be increased to meet the additional requirements.
The balanced diet recommended by the Nutrition Advisory Committee of the Indian Council of Medical Research in 1981 fora nursing mother is as under : The balanced Diet for a nursing mother doing sedentary work.

Cereals Pulses Leafy Vegetables Other Vegetables Roots and Tubers Milk Oil & Fat Sugar or Jaggery 470 gms.

70 gms.

100 gms.

40 gms, 50 gms.

200 gms.

30 gms, 30 gms.

For many mothers milk and eggs may be too expensive to inciude in their न 36 daily diet.
They must, however, know that the inexpensive sources like pulses (dals) and nuts (forexample groundnuts, ‘til’ etc.)

when eaten alongwith cereals or millets such as rice, wheat, bajra, jowar etc.
will provide a goud quality protein and other nutrients particularly minerals required by the body < Care of other factors influencing lactation : Though successful lactation greatly depends on the adequate nutrition pro- vided to the lactating mother, the emotional state of woman is an important factor which decides whether she will lactate successfully or not.

If there are worries and mental strain, it affects the system and the lactation suddenly stops or is greatly reduced.
It is, therefore, essential thal besides taking care of the diet of a lactating mother efforts are made to provide an atmosphere of'love and affection to a lactating mother so as to enable her to lactate successfullySome of the points for consideration for the care of the nursing mother are as under : — Anursing mother should consume a minimum of condiments and spices otherwise the breast-milk will carry these odours making it unpalatable to the baby.
— A nursing mother needs plenty of liquids so as to make up for the toss of body water through milk.

Besides milk she must have enough of water during the day.

— All locally available food-stuffs must be utilised.

There are many cheap foods which are nourishing such as groundnuts, palak, amaranthus, papaya, pumpkin, amia, carrots etc: These must be included in the daily diet.

— Personal hygiene is very important because any maternal infection can easily be passed on to the infant.
Care must be taken to keep the breast clean and to wear clean clothing.

It is desirable to wash hands and breasts before each feed and after feed also, it should be wiped with a wet cloth to avoid the milk drying on the nipple as it may lead to-sore nipple.

— Anursing mother must have the confidence that she can lactate successfully and must have the desire to breast feed her baby.
These two factors are important for successful lactation, — She must try to keep herself happy in all circumstances because emotional stress can depress the lactation, — Anursing mother should try and organise her work in sucha fashion that she has enough time to breast feed her baby.

She must feed the baby in an absolutely relaxed state of mind so as to enable good flow of rnilk.

Encouraging the use of maternal and child care services, supplementary feed- Ing at anganwadis etc.
The community should be educated about the availability of maternal and child care services, provision of food supplements at anganwadis for the lactat- ing mothers and prophylaxis programme against the nutritional anaemia under which iron and folic-acid tablets are distributed to pregnant and lactating mcthers and pre-school children, so that these services are utilised by them.

The nursing mothers must be educated about the need for post-natal (after delivery) care.
There are a number of advantages of regular post-natal care offered by the health centres such as health problems of the mother and the baby can be identified and treated early, the baby can be given necessary immunization and the mother can be advised about infant care and proper feeding and Gan also be given family planning advice.

37 Chapter-7 BREAST—FEEDING The practice of breast-feeding is almost universal in India.
It is, however, on the decline, particularly in urban areas where bottle is fast replacing the breast with disastrous results for the baby- increased malnutrition and infection.

In order to preserve and promote the traditional and sound practice of breast feeding, various aspects of breast-feeding are discussed in this chapter under the following sub-heads : — Nutritional superiority of breast milk.

— Advantges of breast feeding.

— Vaiue of Colostrum.

— Points to be remembered while breast feeding.


— Possible problems during breast feeding and their solution.

— Dangers of bottle feeding.

— Artificial feeding.

Nutritional superiority of breast-milk : Modern Science and technology has not been able to produce a better food for young infants than mother’s milk.

Breast-feeding is the best way to satisfy the*nutritional and psychological needs of the baby.
Unfortunately, there is an alarming decline in the breast-feeding practices — not only in the developed countries but even in many developing countries where artificial milk substi- tutes of very poor quality are given to the babies in the most unhygienic manner thus producing mainutrition and infection.

The inter-action between these two are recognised to be responsible for high mortality and morbidity in infants and children under 5 in most developing coutries.
Every effort should, therefore, be made to encourage breast-feeding.

, Scientific evidence shows that the constituents of human milk and cow's milk are dissimilar in many respects.

The exceptional nutritional quality of human milk has been recognised for a long time.

Mother's milk is designed for easy digestion and assimilation.

Protein in mother's milk is in a more soluble form which is easily digested and absorbed by the baby.

Cow's milk has more protein this.


forms tough curd in the baby's than human milk but a major portion of stomach.

Same is the case with regard to fat and calcium in human milk which are also easily absorbable.

The milk sugar — lactose in mother's milk provides ready energy.

In addition, a part of it is converted into lactic acid in the intestines which destroys harmful bacteria present there and helps in absorption of calcium and other minerals.
The amount of vitamins such as thiamine, vitamin ‘A’ and vitamin ‘C’ found in mother’s milk depends on her diet.

Under normal conditions, milk can provide reasonable amounts of these vitamins, The human milk has inherent anti-infective properties which no other milk has.

This protective function of human milk is particularly important in develop- ing countries where there is much exposure to infection and facilities for the proper and sanitary preparation of infant feeds are lacking.
Advantages of breast feeding : One of the important points for consideration while promoting breast-feeding 38 is to propagate the advantages of breast-feeding.

Acommunity where breast- feeding is a normal practice may not require much education except with those with special problems.

In urban and industrial areas, the traditional practice of breast-feeding should be encouraged.
Since the advertisements of breast-milk substitutes (powdered milk formulae) adversely affect the breast-feeding prac- tice, a field worker should act to reduce their bad effects on breast-feeding.
There are many advantages of breast-feeding, A worker must know and believe in these advantages :— ” a Breast-milk Is the best natural food for babies : Breast-milk contains the right mixture of fats, sugars, proteins, minerals, and most vitamins for a growing baby and is easy to digest, The nutrients in breast-milk are essential for the growing body.
It also contains substances which protect the child from infection, Just like cow's milk is the natural food tor calves, the human milk is the natural food for babies.

Even if cow's milk is modified, it cannot have all the good qualities of human milk fora human baby.

Breast-milk is suited to the growth needs of babies.

Upto 4 months of age no other food is needed.

Starting from 4-6 months other foods.should also be given, but breast-feeding should continue.
Even if a small quantity of mother’s milk is available to the baby it improves the quality of other foods the baby is taking outside.

Breast-milk is always clean : Mother's milk passes straight from the breast into the infant's mouth.

Thus it cannot be infected by germs.

Many germs grow well in milk.

Other milks, such as cow milk, are easily contaminated with germs from dirty hand, spoons, cups, bottles, or flies.
Breast-milk protects the baby from diseases : Breast-milk contains protective substances against the germs which cause have fewer diarrhoea and some coughs and colds.

Breast-fed infections.

babies Breast-milk is available 24 hours a day and requires no special preparation : With breasi-milk there is a speciaJ mechanism of demand and supply.

The more often baby sucks, the moré milk the mother will produce.

Other types of milk need to be boiled before being fed to babies.
They also need to be diluted with water when a baby is small.

The water used for dilution should also be boiled and cooled.

Sugar should also be added.

It is preferbie to boil the milk after addition of the sugar as in most cases, sugar is not clean, All this requires fuel, thus extra time and money, Breast-milk is nature's gift to the Infant and does not need to be purchased.

Most foods cost money, but mother’s milk is free.

An infant who is 3 months old needs 800-700 ml.

of milk per day.
of milk per day.

If breast-milk is notgiven, other milk must be purchased.

In an ordinary home this will mean a large part of the family's income.

There will be extra cost for fuel, (A mother should have extra food when she is breast-feeding, but this costs only about a quarter or fess of the price of are more common when you use other types of buying milk), Illnesses 39 ू प ा ब milk.

Treatment of the illness will Gost both time and money.
Why waste money and invite illness by bottle-feeding: Breast-feeding makes a special relationship between mother and baby : Breast-feeding permits a closeness between a baby and mother.

Every human sense is involved in breast-feeding, This contact includes touching, warmth, smell, looking, etc: If this close contact is started in the first few hours of life, the relationship is especially strong.

Breast-feeding gives a feeling of security and love to the baby and is satisfying for both emotionally.
Physical proximity,fondling,warmth and love of the mother received by the infant during breast-feeding help in his healthy growth and development.

Thus one of the major advantages of breast-feeding is the psychological and social benefit.

Breast-feeding helps parents to space their children : When a mother breast-feeds, her womb-:contracts, There are also other changes in the mother that result from breast-feeding.
Mothers who breast feed do not mensturate as soon after delivery as mothers who give artificial feeding.

Mothers who breast-feed do not generally become pregnant again so soon.

Breast-feeding, therefore, helps in spacing children.

In this way a mother can give full attention toa small child for a longer time before the next child is born.

Of course, breast-feeding is not a certain way of avoiding pregnancy.
If parents want to be sure of not having another baby too soon, they should use some other contraceptive method in addition to breast-feeding.

Breast-feeding helps a mother to shed extra weight gained during pregnancy: Since a mother requires a lot of energy for producing milk, it helps her to shed extra weight gained during pregnancy and after delivery due to consump- tion of rich foods containing a lot of ghee etc.
Mothers who follow the traditional practice of consuming rich foods after delivery but do not breast-feed their babies, will retain extra fat.

On the other hand, a mother who breast-feeds her child can afford to eat any amount of rich foods including ghee etc.

and will still retain her normal weight and figure.

Value of Colostrum : The milk secreted after the child birth for the first few days (2-3 days) is called “Colostrum”.

It is yellowish in colourand sticky.


It must be fed to the child as itis highly nuitious and contains anti- infective substances.

Colostrum has more protein, sometimes upto 10%, It has less fat and the carbohydrate lactose than the mature milk.

It is very rich in Vitamin ‘A’, Feeding the colostrum to the baby heips him to build his stores of nutrients and anti-infective substances (anti- bocies) in his body.
The anti-infective substances protect the baby from many infectious diseases such as diarrhoea, to which he might be exposed during the first few weeks after birth.

Some mothers consider this first milk as something dirty and indigestible.

Difference in colour and consistency could be the possi- ble reasons for such beliefs.
It is, therefore, important to educate the mothers about the value of colostrum, In view of the special desirable features of colostrum, mothers must see that colostrum is not wasted but fed to the child.

Points to be remembered while breast-feeding : Mothers in the rural areas are expert in breast-feeding.

They learn from watching their own mothers, relations and neighbours breast-feed their babies.

40 They learn naturally and do not need special education.
But mothers in urban areas, especially those with a first child, quite often need advice on specific matters.

The points to be remembered while breast-feeding are elaborated here in the form of answers to questions mothers may ask, When should mothers start breast-feeding ?

A mother should start breast-feeding as early as possible after birth itis best to start very early, within one or twohours of birth.
Though there is little milk at that time, it helps to establish breast-feeding and a close relationship, Can all mothers breast-feed their babies ?

Yes, practically all.

There are very few conditions in which a mother cannot feed her baby.

Difficulties of breast-feeding are discussed later.

How do you put the baby to the breast ?

A mother normally knows this.

Only teach her if she is having difficulty The mother should be comfortable.

After delivery, sitting up may be painful.


The mother or baby can be supported by pillows, or she may feed the baby while lying down on her side with the baby beside her If she touches the baby’s cheek with her nipple, the baby will automatically turn his head and open his mouth.

Not only the nipple, but also the areola (the dark skin around the nipple) should be in the baby's mouth.

The baby’s chin should be pressed up against the breast.

I!
I!

the breast is very full, it may press against the baby's nose and make it difficult for him to breath.

To avoid this the mother should lean towards the baby.

She can also gently hold the breast away from the baby’s nose with her fingers.

The baby should suck from both breasts at each feed.

Feeding should start with the right breast on one occasion, and the left breast on another.
If the mother can relax, the milk will flow easily and she and the baby will enjoy the closeness and satisfaction of breast-feeding.

How often should the mother breast-feed ?

The more often the baby sucks, the more breast milk will be produced by the mother.

Allow the baby to breast-feed whenever he wants.

During the first few Gays the baby will cry when he wants milk; mother and baby usually settle into a rhythm.

It is not a good thing to feed at a precise time according to a clock.
How long should a baby be fed each time ?

The baby should be allowed to suck for as tong as he wants.

At first the time may be quite short, 5-10 minutes frdm each sida.

When the baby gets older and stronger he will suck for 4 longer time becuse he needs more milk.

Should the baby be fed at night ?

Small babies need to be fed at night.

In the first few weeks of life most babies wake up with hunger in the night.

They need extra feeding.


In many countries babies sleep next to their mothers, There is no danger of a mother crushing her child.

Babies enjoy the warmth and closeness of the mother's body.

Many babies feed at night sometimes without waking the mother, 41 Up to what age should a child be breast-fed?

A baby should be breast-fed for as long as possible.

It is good to breast-feed for at /east one year.


Breast milk is still important for growth in the second year of lifebecause even a small quantity of breast milk along with other foods can improve the diet of a two-year old chiid.

How do you know if the baby is getting enough breast-milk ?

Most mothers produce enough milk fora baby to grow well for the first 4-6 months of life.

Growth should be measured by weighing the baby regularly, How should breast-feeding be stopped ?
Ifa mother wants to stop breast-feeding, she should do it gradually.

Stopping breast-feeding should not be sudden because the baby will need some time to get used to other foods.

Other foods should first be introduced and increased over.a period of 2-3 months.

Then the baby will suck less, and less milk will be produced.

Should breast-feeding be stopped if the mother becomes pregnant ?
It is Not necessary to stop breast-feeding when a mother becomes preg- nant, The quality of her milk will still be good, but the quantity may decrease.

Breast-feeding for the first few months of pregnancy will cause no harm to the child in her womb, A pregnant mother whois also breast-feeding will need extra food.

Itis not good fora mother to become pregnant soon after she has had a baby.

She will not be-able to give the first child breast-milk long-enough.
What can a working mother do about feeding her baby when she is away at work ?

If she is going to be away for ashorttime, she should feed the baby just before she leaves.

lf she has to.be away for a long time, she should try and take the baby with her.

The baby can be fed anywhere.

If she must leave the baby she should make good arrangements, Another mother may give the baby a breast-feed.

If the baby can take other foods, something should be carefully prepared and preserved for him.
A responsible person should be shown how to feed this food to the baby when the mother is away.

Should the baby be given occasional feeds from a bottle?

It is not desirable to give occasional feeds from a bottle to the baby as this depresses the lactation, If extra feeds are given, the chiid will suck less and hence less breast-milk will be produced.

Besides, a small baby does not require extra feeds.

Mother's milk is sufficient upto 4-6 months.


Boiled water may, however, be given in between feeds specially when the child has diarrhoea or fever.

But, if itis absolutely unavoidable, then the child should be given top feeds with a Cup and spoon ora tumbler as these are much easier to be kept clean than feeding botties.

Can contraceptive pills be taken while breast-feeding ?

Most contraceptive pills reduce the amount of breast-milk.
Lactating mothers should use pills which do not affect milk production or preferably use other methods of avoiding pregnancy during the period of breast-feeding.

This is important because a baby should receive breast-milk for as long as possible.

42 Possible problems during breast feeding and their solution : There are a few common problems with breast-feeding, especially in the first one or two weeks.
The most frequent are a mother's anxieties about her performance and the amount and quality of her milk.

Others include flat nipples, sore nipples, and very swollen and tender breasts.

Preparation for breast-feeding during pregnancy can avoid a number of these problems.

Every mother should contact health worker during pregnancy and discuss breast-feeding.

Some of the common problems and their solution are discussed below ; Flat nipples : Some women have short, flat nippies.
The baby will have difficulty in sucking from such nipples.

This is most common in women whoare having their first child.

Most nipples are protractable and quite fong.

Mothers should be taught to massage her nipples.

to press them and pull them gently for several minutes every day during pregnancy.

After the baby is born, nipples can still be stretched further.

The mother should squeeze the areola before putting the nipple in the baby's mouth.
If the breast is very full, first express some milk before doing this.

Swollen (engorged) breasts : Sometimes a mother's breast make more milk than her baby needs.

This is quite common in the first week after the baby is born, Sometimes the baby is too weak to suck all the milk.

Ifa breast is not emptied normally, it becomes painfu!

and swollen with milk (it becomes engorged).

The skin is tight and the baby cannot put the whole areola in mouth to.

suck.

Sucking may be very painful to the mother.


To prevent and treat engorged breasts, empty them regularly by expressing, Expressing breast milk: Teach a mother to express her milk when her breasts feel painfully full.

She should wash her hands and find a clean cup or bowl Using both hands squeeze gently from the base of the breast towards the nipple.
Then squeeze the breast and areola between fingers and thumb and let the milk squirt into the cup, Milk must be expressed from each part of the breast You cannot express a breast quickly.

An empty breast should be soft without any lumps, If an engorged breast is not emptied, the amount of milk produced by it will decrease quickly.

The expressed milk can be fed to the baby through cup and spoon.

A tender lump in the first week of breast-feeding may be caused by a blocked milk duct in the breast.
Empty the breast and then gently press and empty the lump, This will prevent serious problems later.

Sore nipples : Nipples are very sensitive.

If the skin is very soft and the baby sucks very hard.

soreness develops.

This happens more in women with engorged breasts and in women with smail or fiat nipples because the baby is not able to take areola in his mouth and has to suck extra hard to hold the nipple in his mouth, Sometimes the soreness develops into a crack which is very painful.
A crack is Not usually due to a baby biting the nipple.

Infection can get into the breast through a crack in the skin.

To prevent sore nipples keep the skin soft by rubbing the areola and nipple with some oil before the bath, Do not let the baby suck for too long at first.

Change the position so that when the baby sucks the line of pressure will not always be at the same place.

Make sure the breasts are emptied regularly, by 43 expressing them if necessary.
Wipe the nipples with a clean wet cloth and dry in the air after feeds, Treat sore nipples by keeping the breasts empty.

Sucking is usually too painful, and it will be necessary to express the milk.

Put some antiseptic omtmenti{e.g boroline) or antibiotic ointment (tetracycline) on the crack.
Let the child feed from the other breast If necessary, give the mother aspirin or paracetamol tables to rehkeve tne pain Painful tender breasts with fever : Sometimes germs enter the breasts, perhaps through a crack in the nipple Tms causes infection.

A part of the breast becomes painful, swollen.

red and warm, The women may have fever.

Anubiotic treatment may be needed and the mother should be referred to the health centre or hospital.
In this casealso it is important to keep the breast empty of milk by feeding or expressing.

The breast will be very painful, but the baby should go on sucking.

Breast-feeding should be stopped only if there is pus Coming Out from the nipple.

The mother Can be given aspirin or parace- lamo!

tablets to relieve the pain and fever.

Fears that there is too little milk or that it is of poor quality : In the beginning, i!

is common for mothers to worry that they do not have enough milk for thes, babies.
Breasts begin secreting milk from the third to the fifth day atter delivery.

However, during the first 2-3 days after delivery, breasts secrete enough Colostrum to feed the baby.

Encourage the mothers by telling them.

- Milk usually starts to flow on the third to fifth day, but breast-feeding should be started immediately so that the baby can get the colostrum.
Immediate breast-feeding will promote early milk secretion, — A baby is born with plenty of water in his body and does not need to drink much in the first few days.

~ The baby should be put to the breast regularly.


He will get some colostrum which is good, and sucking helps the milk to come; Often mothers of 2-6 month-old babies worry that the baby is not getting enough milk, especially if the baby cries a lot, Help the mother in the following ways - Weigh the baby regularly If there is steady weight gain, reassure the mother The baby may cry for reasons other than hunger.
Make sure he is not wet, cold, or uncomfortable Crying after feeds is not usually due to hunger but due tothe air inhaled while drinking milk.

The child should be burped after each feed by putting him against the chest of the mother with his head on her snouider anc patting him gently on his back.

ifthe baby is not gaining weight well, try fiest to increase the mother’s milk She should have more toed, drink, and rest.

Where culturally appropriate.


give locally accepted nerhs and drinks to increase breast milk.

The baby should be pul to the ores?

more often to feed — Heip ine motner tu overcome any other anxieties.

because-anxiety can Gecrease ner milk flow ~ Even if a mother Sas univ 4 little b-east nulk, she must continue Dreas!
mick sne 'ias is good, and she may have feeding herch.c What ver fresco more later if she preserves Mothers sometimes worry that ineir milk is not suiting the baby, or that it sof poor quality.

Ignorant women and grandmothers sometimes say such things.

In fact a mother’s milk is just rignt for her baby.I1 contains nounshment and ' a4 substances that provide protection from infections.

Strong reassurance should be given because if a woman losses confidence, her milk supply may decrease.
Dangers of bottle feeding : Artificial feeding with “feeding bottles” is very common in well-to-do urban families and is getting popular in the middle and low income families of urban as weil as rural areas.

Baby foods advertising has contributed to this change toa great extent.

Baby foods are now available even in remote rural areas.

High incidence of diarrhoea and malnutrition are common in artificially fed infants.
Such infants are not only deprived of mothers milk bul in addition are exposed to many infections.

The common practice of bottle feeding is dangerous, Some of the reasons why bottle feeding is dangerous are given below - — Except for breast milk, no other milk has any substances that can protect the child from infections.

— Milk is easily contaminated with germs from dirty bottles.

rubber teats, spoons, water, or hands.


— Often the bottles with left over milk are kept exposed to flies and dust which become a source of infection thus increasing the risk of intestinal infections This danger is greatest in homes where there is no running water supply and where there is little fuel or time for sterlizing the feeding-botties and teats — Milk goes bad if it is not used quickly.

This happens much more quickly in hot climates.

.


— The rubber teat of the bottle may have too small or too large a hole.

!f the hole is loo small the child may struggle to get the milk and swallow a lot of air but not anough milk.

Too large a hole may cause rapid feeding and som- times vamiting.

— Cow's milk & powdered milk are often diluted too much: This is because they cost-so much.
If they are diluted the children do not-get adequate nourishment & will not grow Artificial Feeding : if the mother of a small baby has no breast milk, orif the mother has died in childbirth, efforts should be made to find some one else who Can breast-feed the child.

A friend cr relation may act as a wel-nurse.

A wet-nurse is some womer other than the mother who breast-feeds a baby Ever ifa woman is nol lactating and does not have a small baby she may be able to breast-feed the baby.
The baby must be put to both her breasts frequently She should also nave extra food and drink, If there are local herbs believed to increase breast milk.

she should use them.

This process |s called ‘relactation” Relactation does not work with all women.

If the mother really cannot breast teed and a wet nurse cannto be found, then it will be necessary to give the child artificial feeding with milk from a cow or other animai or with powdered milk.
Since bottle feeding may prove to be dangerous if proper methods a!

prepi., ing bottle feeds are not fallowed, the following precautions should be observed in order to decrease the dangers of artificial feeding — Hands should be washed with soap and water every time before preparing the feed.

— Use other methods of feeding rather than a bottle.

Feed with a cup and spoon, or a tumbler.


Trey are all much easier to clean than a bottle — If feeding bottles have to be used these must be thoroughly cleaned anc 45 sterilised (boiled in water), Tne bottle and the rubber teat should be properly cleaned with soap and water, rinsed thoroughly and then boiled in water for a few minutes.

The water in the vessel should be sufficient so as to cover the bottle(s).

The cleaning should be done with safe drinking water.

— Wash the bottle after each feed.


Do not let the milk remain.in the bottle after feeding the baby as it is a good medium for the growth of bacteria.

— If using powdered milk, mix the correct amounts with boiled and slightly cooled water for preparing the milk.

Diluted milk formulae are one of the important causes of malnulrition.

— Mix up only the amount that is needed for one feed.

If too much is mixed and some stored for a later feed, the danger of contamination is great.
— If the family cannot afford to buy enough milk for the baby, the baby will need milk and porridge to give him enough nourishment.

It must be remembered that artificial feeding is to be taught only to mothers who have no chance of breast-feeding.

Do not teach about artificial feeding toa group of mothers.
Antificial feeds should not be generally used to supplement breast-milk as this reduces the production of breast milk: in certain cases, it may be necessary to supplement breast-feeding with artificial feeding if the growth chart of a child shows that he is not gaining weight.

itis advantageous to use cow's/buffalo's/dairy milk than the powdered tinned milk formulae since the former is comparatively cheaper and easy to prepare.
Some of the instructions for using cow’s/duffalo’s/dairy milk for artificial feed- ing are as uncer : — Boil the milk.

This makes it safer and more digestible, — Dilute the milk for young babies.

During the first 15 days of life: Give 1 part of boiled and cooled milk diluted with 1 equal part of boiled and cooled water.

— From 2 weeks to 4 months of age : Give 2 parts of boiled and cooled milk diluted with 1 part of boiled and cooled water, — After 4 months of age : Give undiluted boiled and cooled milk.
— Remember that milk may have already been diluted before it was bought.

The dilution would, therefore, have to be adjusted accordingly.

— Add 1% tea spoon of sugar for 6ach cup of milk.

How much does a baby need ?

An artificially fed baby needs about 150 ml of milk for each kilogram of his own weight each day.

If pounds and ounces are used in weighing and measur- ing the rule is to give 2.4 ounces of milk per pound of body weight of the baby.

One kilogram is 2.2 pounds and about 30 ml is one ounce.
Soa very young baby weighing 3 kg.

will need 450 m1.

of milka day.

He needs feeding about 6-8 times a day; therefore, he will need about 55-75 mi, of diluted milk at each feed.

Feed little older babies 5 times a day.

A5 month old baby weighing 7 kg.

will need a more than 1 litre of undiluted milk aday sbout 210 mi, at each feed.
Some of the important points to be taught about artificial feeding are : — — Breast feeding is the best feeding until a child is 18-24 months old, but additional foods should be given when the child reaches 4-6 months of age.

Mixing and preparing powdered milk is very complicated.
Anyone who needs to use powdered milk should have a demonstration from a trained person Itis very expensive to teed a baby with the correct amounts of powdered mitk — 46 Chapter-& FEEDING INFANTS Ignorance about the correct feeding practices, particularly for infants, is one of the important causes of malnutrition among young children.

Education of mother regarding feeding of infants snould, therefore, receive sufficient atten- tion.
A field level functionary should have sufficient knowledge on the following aspects of feeding infants so that she can advise the community in a more purposeful manner : — Importance of nutrition for infants.

— Need for supplementary feeding.

— When to start supplementary feeding.

— Types of supplementary foods.

— How to introduce supplementary foods.

— How much and how to feed.

— Increasing the energy density of infant foods.

— Feeding the sick child.
— How to make sure that foods for infants are clean and safe — Utilising the available nutrition and health services, importance of Nutrition for Infants : The nutrizion of infants and young children is causing great concern amongst 47 — scientists and planners because child is the chief victim of the inter-play of nutritional, socio economic and heaith factors that cause malnutrition, Rapid growth and development of the body during this period indicate the need for increased nutritional requirements during this period as compared to the adults.
Some of the factors which make the nutrition during infancy a matter of great importance are as under : Rapid growth : infants grow at a very rapid rate.

The rate of growth at this stage is uncomparable to that during later period of life.

Growth is very fast in the months immediately after birth.

An infant weighing around 3.0 kg, at birth doubles its weight by 6 months.

By one year the weight trebles and the body length increases to one and a half times than at birth.
Most of the organs of the body grow rapidly, both structurally and functionally, during the early years of life and then later on, the growth slows down.

Growth periods are different for different systems of the body.

For example, most of the growth in the nervous system and brain is complete in the first two years of life.
In order to achieve optimum growth and development, there is an increased demand for a regular supply of raw-material in the form of better nutrition, Transitional period : The beginning of weaning is the beginning of atime of great change for both mother and child.

Weaning is a process through which an infant is accustomed to take food other than milk.
This is the most crucial phase in the nutritioinal history of man since most cases of severe malnutrition occur in the post-weaning period and are generally due to the bad weaning practices.

Malnutrition is more common during this transitional period than in the first 4 to 6 moths of life, because families may not be aware of the special needs of the infant and may not know how to prepare food for the infant from the foods that are focally available.
Higher rate of infection : Weaning is a dangerous time for infants as thereisa higher rate of infection, particularly of diarrhoeal disease during weaning than at any other period in life.
This is because the diet changes from clean breast- milk which contains anti-intective factors, to toods whith are often prepared, stored and fed in unhygienic ways Food fads and taboos : The food pattern of infants is greatly affected by superstitions, taboos and wrong beliefs of the mothers regarding the suitability of solid foods for infants.

Weaning is, therefore, started at different times in different communities.
In-some communities solid foods are introduced to infants after they have gol teeth or they have iearnt sitting up.

In some communi- ties no cereals are given to the infants tilla ceremony called ‘annaprashana’ has been performed, As a result, the weaning does not start until the infant is in the second halt of first year and may sometimes extend over more than two years, In urban communities.

on the other hand, weaning often starts mucn earlier.
Additional foods may be given to the infant when he is only a few weeks old thus increasing the risk of infection.

Nutritious foods like mango, curd (dahi) etc.

are not given to infants due to concept of hot and cold foods.

The feeding of infants is, therefore, greatly influenced by the prevatent food fads and taboos and the ignorance:of the mothers about the correct feeding practices.
Need for supplementary feeding : Infant feeding comprises breast-feeding, artificial feeding and supplementary feeding, Breast-milk is an excellent food and, therefore, this feeding should be 48 encouraged, However, after 4-5 months.

breast-milk alone is nol enough to make an infant grow well, other foods ere also needed.

This is because the infantis growing is size and his activilies are also increasing.

As a result his nutritional needs also increase significantly at this age.
Bc cast-feeding aloneis not sufficient to meet the increasing needs of infant after the age of 4-5 montns No mother, however.

successful she might be in lactation, can ever satisfy the nutritional needs of her baby beyond 6 months of age.

While protonged breast- feeding is extremely desirable, the need for supplementing the diet with other foods after the age of 4-5 months is equally important and should receive sufficient attention.
Supplementary feeding is also known as complementary feeding and is designed to supplement/complement the breast-feeding of the infant.

The period during which the infant's diet changes from milk alone toa regular family diet is called the weaning period.

Solid foods prepared in suitable consistency are required by the infant along with breast-feeding to satisfy his increased requirements of energy, protein.

iron, calcium, and vitamins.


When to Start supplementary feeding : Breast-milk on its own is sufficient for most infants until 4 to 6 months of age, Some infants continue to grow satisfactorily for 6 months or even for short time after that (say upto 7 months), Others, apparently needing more energy and nutrients than the breast-milk can provide show sings of hunger and/or a slowing in weight gain around 4 months or even earlier.
The best time to introduce supplementary foods is when the child shows signs of "growth faltering”.

In other words when infant's growth starts slowing down, as evident from his growth chart, the supplementary feeding should be started, This period could be 4 months for some Infants and may be even 7 or 8 months for others However, most infants need additional foods by the age ef 6 months.

The supplementary feeding should, therefore, be started when the child is 5 to 6 months old.
The purpose of these foods is to complement the breast-milk and make certain that the young child continues to have enough energy, protein and other nutrients to grow normally.

it ls important that breast-feeding is continued for as: many months as possible as it provides useful amounts of energy and good quality protein.

itis not desirable to start supplementary feeding too early 1.6. before 4 months of age as it increases the risk of infections, particularly in lower socio-economic groups.
Two things need to be balanced while deciding to introduce supple- mentary feeding, firstly the baby should not suffer under-nutrition for want of supplementary foods ana secondly the addition of supplementary foods in infant's diet should not lead to increased risk of infections.

Types of supplementary foods : Most mothers are ignorant of the importance of supplementary foods for the growth of infants.
From a purely milk diet, the infant is either given a piece of chapati or a biscuit which he nibbles and spits it out, or where the awareness is slightly better, the infant is given dal water, thin clear soup, fruit juice ete.

It is, therefore, important that the education of the mother concentrates on what foods to be given to the infants, at what age, in what form and in what amounts.
It is also important to keep the economic status of the family in mind while advising about supplementary foods for infants since these can be prepared 49 from the foods cooked for the family or as special foods for the infants.

The supplementary foods can be preapared specially for infants if the time & resources permit.

Otherwise the food cooked for the family can be modified into a Supplementary food.

There are certain traditional supplements like khicheri, porridge (dalia) etc.
which have been used to feed infants.

Besides, Instant Infant Foods can also be prepared and stored at home for a month or two.

First food for the baby : The staple cereal of the family should be used to make the first food for an infant.

A porridge can be made with suji, broken wheat, atta, ground rice, ragi, little water cr milk if available.

The cereal snould be weil millet etc.

by using a cooked and mashed so that it is soft.


Sugar or Jaggery should be added to the porridge as it increases the energy value of the food.

Mix alittle oil or ghee in the porridge ta increase its energy value.

In the beginning this porridge could be made very thin but as the child grows older the porridge should be made thicker.

A thick porridge is more nourishing thana thin watery gruel.
Give one to two tea-spoons twice a day to begin with and gradually increase over the next 3to 4 weeks So that by that time the baby is taking 50 to 60 gms.

of porridge (half 8 ७७७).

The cereal porridge could be intraduced when the child is about 4-5 months old.

In case a family cannot prepare the porridge for the infant separately, it should be advised to’ soak pieces cf one chapati in half a-cup of milk or weak tea, mash properly and feed to the baby.
If required the soaked and mashed chapati could be passed through a sieve so as to get a smooth semi-solid food for the infant Fruits like banana, papaya, chiku, mango etc.

can be given at this age ina mashed form, Infants.

can also be given reconstituted instant infant foods (preparation of which is discussed a little later) at this age.

Mixed food for infants : By the time the child is 6 months old, he is taking some cereal porridge and some seasonal fruit.
Once the child is eating the cereal porridge well, cooked pulses and vegetables can be mixed with cereals cr given separately.

Well cooked dal can be mashed and given to the infant.

Vegetables like carrots, potatoes, spinach be boiled or steamed, mashed and given to the child, Some butter, ghee or oil should be added with these vegetables before feeding.

Itis no point feeding dal water or thin soup as it does not have much food value.
The child should be fed with mashed vegetables or well cooked pulses in a semi solid form Preparation of special foods for infants may not always be possible for every body because of lack of time and resources, Modification of the family's diet into an infant food needs to be taught to the community.

Modifying Family's Diet : in most families, there is a cereal preparation in the form of roti or rice and a pulse or a vegetable preparation.
For preparing a supplementary food for the infant from the foods cooked for the family, a small amount (a karchi each) of dal or vegetable preparation should be separted before adding spices into it.

In wheat eating areas, pieces of one chapati could be soaked in halfa katori of dal, 50 mashed and passed through a sieve, In case some vegetable(s) has also been cooked for the family, a karchi of cooked vegetable without the spices could also be added in the chapati and dal mixture.
A tea-spoonful of oil should be added to the sieved mixture and fed to the child.

The consistency of the semi-solid food thus prepared from the family diet can be adjusted according to the needs of the child by adding a little boiled water, if required.

Similarly rice eaters can soak rice into dal or a vegetble preparation or both, mash and sieve the mixture for feeding the infant.

‘Idli’ soaked in unspiced sambhar can also serve as a supplementary food for infant.
Khicheri is an excellent example of the mixed foods used for infants during weaning period and is one of the traditional foods used for infants, ‘Bhat’ is another traditional weaning food used in rice eating areas particularly in eastern States, There may be many more foods commonly used by a community for feeding infants which may require a little modification to make them more nutritious.
For instance, bhat can be made more nutritious if the mother is taught to add some cooked dal and vegetable to it or some cooked fish or milk if available.

Similarly Khicheri can be made more nutritious by adding one or two vegetables (say potato/tomato/carrot and one green leaty vegetable) in it while cooking, All the ingredients i.e.
rice, dal.and two vegetables can be cooked together with salt, when well cooked, it can be passed through a sieve to get a semi-solid food which can be fed to an infant after adding fat or oil.

For younger infants, the khichri could be cooked with a little more water so that after it is passed through a sieve, a semi-solid food of pouring consistency is obtained (a sort of thick soup).

Remember, as the child grows older, it may not be necessary to pass the mixed food through a sieve.
The child can be fed weil cooked and mashed mixtures of cereal, pulse and vegetables with addition of fat and oil, Modifying family’s diet is thus one of the most effective ways of persuading the mothers to prepare supplementary foods for their infants, since tt does not require extra food, fuel and money and can be prepared easily in a little time.

Mixed foods can also be prepared separately for infants if the mother has both time and resources.
Cereals, pulse and vegetables can be cooked together with a little salt to prepare a thick soup.

The preparation of some of the mixed foods for infants is given at the end of this chapter, In the second haif of the first year of life, a child can take a more varied diet Foods like curds, egg, kheer, dalia, bread etc.

can also be given.

Thick rotican be softened in milk, dal or gravy and fed to the child.

The egg can be given as boiled, scrambled or poached.
If egg can be fed to the child, introduce by giving only the egg yolk in-the beginning as some chiidren may have some allergy to egg which is more pronounced in case of egg white.

If the child accepts the egg yolk Well, whole egg can be given.

The popular belief that raw-egg or half boiled In fact it is always €9g is more nourishing than cooked egg, is not correct.

desirable to feed the egg yolk of a full boiled egg to the child.
For younger infants, this egg yolk could be mixed with a little milk and butter before feeding.

Egg should preferably be introduced in a child's diet after the age of 6 months or even later.

Biscuits are commonly used even in remote rural areas for giving to the children.

Mothers must be taught not to divert their precious resources on items like biscuits since the amount of food vaiue of biscuit is too less as compared to its cost.
The biscuits could, however, be used if there is a bakery in the village producing these items and making them available at a reasonable rate to the community.

51 Seasonal fruits like banana, papaya, guava or mango should be given to infants, if available..Carrots and pumpkin can be fed to the infants by grating and cooking with sugar or jaggery.
Minced meat and fish can be given to infants in non-vegetarian households, Home made instant foods for infants : Modification of the food from the family pot is possible only twice a day since there are usually two major meals prepared in a day while a child requires to be fed 4-5 times a day.

It is, therefore, necessary to prepare some infant foods from roasted cereals and pulses which could be stored in air tight containers to fast fora month orso.
Such toods could be constituted with boiled wateror milk and fed to the infant during the time when freshly cooked food is not available.

The home made instant infant foods are as good as commercial infant foods availa- ble in the market and can be prepared at a very low cost.
Mothers must be educated about the disadvantages of commercial infant foods such as high cost with no extra benefit, do not help develop good food habits in children and so on Instant infant foods can be prepared using any of the cereal or millet and a pulse.

The proportion of cereal and pu!se can range from 2: 1103: 1.

Roasted groundnuts or til could also be added in the proportion of 4: 1 (4 parts of cereals and one part of groundnut).
The ingredients should be roasted separately, ground and mixed in the desired proportions and stored in an air-tight contain- er.

The roasting could also be organised at a community level with the help of village leaders since roasting in hot sand gives better results.

For feeding, 3 table spoonful of instant infant food thus prepared can be mixed with a small amount of boiled and slightly cooled water and fed to the child after adding sugar or jaggery.
The instant infant foods could also be fed to the child after reconstituling them in dal water, gravy or milk.

It is, therefore, desirable to add sugar or jaggery while preparing the feed rather than in the mixture to be stored so that it can be used in both sweet and savoury preparation.
The preparation of some of the instant infant foods is given at the end of the chapter food after the first year : After the first year, a child is usually able to eat the food prepared for the family, In other words, he starts sharing the family diet.

The food may, however, have to be soft enough for the child and given without spices.

By this age, the mother probably has only 200 to 300 mi of milk, and hence the bulk of the calories has to be supplied by the solids.
It is good to serve food on to a separate plate fora young child so that it is possible to see how much a child has eaten, Care shouid be taken to include atleast 3 kinds of foods, Duringcooking, it may be necessary to remove a portion fora young child before adding strong spices.

The stools of a child will change when he starts eating a mixed diet.

The mother should be warned about this.

A healthy breast-fed child has soft yellow stoois.


When a child eats other foods, the stools become more like adult stoois- How to introduce supplementary foods : Introducing supplementary foods to young infants is an art.

Very often 52 mothers complain that the child refuses to take any solid food.

In order thal supplementary foods are accepted by the infant, certain considerations should be kept in mind while introducing these foods in the diet of young infants.
To train an infant to chew and become accustomed to new foods.

give only one to two teaspoonful of cereal porridge (for example suji kheer), boiled and mashed potatoes, cr freshly peeled and mashed banana, Give the food when the child is hungry i.e.

before breast feeds.

In the beginning, the cnild may spit out the food.

This should not be taken as refusal to the food.

Since the child is iust learning to chew and swallow asemi-solid food tor the first time.

he may spit it.
he may spit it.

Spitting may also be there initially whenever a new food is being introduced as the child may not be used to that taste and may iake some time to accept the same.

Feeding the child with a new food when he !s hungry will lead to better acceptance by the infant than when he is full.

Introduce only one food at a time.


If cereal porridge ts introduced, feed the child with only cereal porridge tor a few days till he develops a taste for it and starts accepting it, Introducing a variety of foods at the same time does not help since the child is not able to develop taste tor any single food and hence may refuse all the foods.

Wait for few days after introducing another food to him Do not force the infant to eat any food.

Forcing may result in refusal to that food.


Remember that a child has to get used to new textures, new tastes.and to spoon feeding.

Keep trying everyday until the intant takes the food well.

Oncea new food is accepted, give the breast-feed first and the food after the breast- feed or the food could be given between two breast feeds, In this way, the baby wil!

suck the breast hard because he will be hungry.

This will ensure a continu- ous supply of breast-milk.
Remember, breast-feeding should continue for two full years, if possible.

Once the child is used to the new food and flavour, the amount of food offered to him should be increased gradually.

He should be given at least 3 table spoons of food for each meal.

If he can take more, more should be given.

If he is unwilling to take this amount, it may be necessary to divide the amount into two smaller meals.
If this is done the amount preserved for the second meal should be carefully protected from flies and dust in a covered container and shouid be preserved only for one to two hours and not longer The frequency of giving supplementary feeds should also be increased gradually.
At first, one to two tea spoons of food are given twice a day The amount of food and the number of feeds per day should be increased gradually By 6 to 9 months of age, child should be given supplementary foods 3-4 times a day in addition to breast-feeds How much and how to feed : One of the important things to consider while educating about suppiemen- is tary feeding is the quantity of food to be given to the child.
Most often it observed that mothers give a variety of food to their children, but in very smal!

quantity, which does not contribute much to nutrition, Asmail piece of chapati, a biscuit or a piece of carrot given toa child which he just nibbles and spits it out is Not sufficient to meet his increased nutritional needs.
Similarly, dal water, 2 thin soup, one or two spoons of bhat are not sufficient for a growing infant, The mothers must be told that a one year o!d infant requires half the quantity of food the food she consumes during the day and that a child can take all that provided is given in right consistency, distributed evenly during the day.
Itis nat sufficient 53 to tell a mother that a child snould be given khichri or dalla, It is necessary to demonstrate to her in household measures the amount the child should be fed at each time.

As already discussed, when a child is just starting to eat.

two tea spoons may be enough but when he is used toa new food, 3 tablespoons should be given for each meal, Similarly the consistency could be slightly thin in the beginning but as the child grows older the feed should be made thicker.
An example of a day's diet for a9 months old infant is as under : 6.00 A.M. 8.00 A.M. Breast-feed.

1/2 katori thick cereal porridge or 1/2 chapati soaked in 1/2 cup milk, One banana and breast-feed.

One Katori khicheri or one katori cereal pulse vegetable mixture.

Breast-feed.

1/2 katori atta halwa or one slice or 1/2 chapaii in half cup milk or 3 tsp of instant infant food recostituted in milk or water Breast-feed.

One katori cereal-pulse-yegetable mixture Breast-feed.

10.00.
10.00.

A.M. 12.00Noon 260 P.M. 4.00PM 6.00PM BOO PM, Bed time inthis way, achild can be given about S breast-feeds and 4 supplementary feeds which include cereal porridge, seasonal fruitand mixed food.

Feeding smal!

children should be a priority within the family.

Feed the young child first because he eats slowly and cannot compete with older children and adults.

Feed the girls as much and as frequently as the boys.
Itis good fora small child to have his own plate and portion of food, Itshould be remembered that there are no set rules about feeding.

It has to be a matter of common sense, Like grown ups, babies too like a particular food more than another, and are more hungry On some days than on others.

Force feeding should be avoided, Meal times should be pleasant and nota torture.

The bow!

or plate used for feeding infant should be such that they can be easily cleaned.
The edges should be rounded so that they do not hurt is convenient and hygienic to feed with a spoon, hand the child.

While it feeding should not be looked down upon since this isan accepted method of eating in most parts of India.
What should be stressed is that the hands should be washed thoroughly before feeding and the nails should be kept short and frequently scrubbed, The mother may understand the nutritional needs of her child and methads of feeding, but she may nat be available for feeding the baby at all the times because she may be away from home for work.
It is, therefore, important that nroner instructions for feeding the baby are givan fo the person who ts looking after the vaby in the absence of mother, Increasing the energy density of Infant foods: Most of the foods are bulky and a child cannot eat more at atime.

Hence frequent feeds are required to be given ane the child may eat every two to three hours.

Besides giving frequent feeds it is necessary to increase he energy value of the foods giver to children; This canbe done in many ways .
DY The energy value of the supplementary feed can be increased by adding sugar or jaggary into it, since these do not increase the bulk but provide energy.

Another important way of increasing the energy value of food is to add fat or oil in the food prepared for the child.

This is very important because 1g.


of fat provides more than double the amount of energy provided by other foods and at the same time it does not increase the bulk of the food Fat also makes the food more palatable and thus increase the acceptability of the food for the infant.

Some mothers may feel that fat should not be given to the child as it is difficult to digest.
This is not correct and this wrong belief should be overcome by explaining to the mother that even the breast-milk which a new born takes contains some fat and the amount af fat going to the child through breast-feeding may be about two to three teaspoons in a day, Fat is present in almost all foods.

When a child can digest the fat present in milk, cereals, pulses etc., the child can also digest the fat.and ol added to his feed.
The mothers must be told that it is necessary to add fat or oil to the child's feed because a child cannot take more at a time because he is small and hence concentrated sources of energy such as fat are required to make j his food nutritionally adequate.

Recently, it has been shown that ‘malting’ reduces the viscosity of the foods.

Malting is germinating the cereal and pulse, drying them after germination and grinding.
Mixtures of cereals and pulses if prepared in this fashion will be less viscous (thick) when reconstitued with water or milk and hence will enable more quantity to be fed to the child.

It has also been shown that malted food thus prepared when added to other foods, help in reducing the viscosity of the food in which it has been added.

Itis, therefore, important that maited foods are included in the diets of children.
Malting not only reduces the viscosity of the food and increases its energy value but it also increases the amount of vitamins of ‘B' complex group in the food and makes the food easily digestible.

Another way of increasing the energy value of food is by feeding reasonably thick mixtures to the child, A thin watery gruel does not have much food and hence does not add much to the nutrient intake of the child.
Even when the child is small and does not have teeth, semi-solid foods can be fed to himinstead of watery foods.

The only precaution to be taken is that there should not be hard pieces in the semi-solid food which may cause difficulty if swallowed, The semi-solid foods for young infants can be passed through a sieve to ensure that they are smooth and uniform and without any big pieces or lumps.

Care should be taken that even the dal, Khicheri etc.
which are to be fed to the infant are not too thin or watery because the bulk of the feed in that case will be water only, whereas the objective is to give solid foods to the child to provide enough energy, protein and other nutrients.

Feeding the sick child : During the weaning period young children often suffer from infections like diarrhoea, measles, cold, cough etc.

If their diet has been adequate, their symptoms are usually less severe than those of under-nourished children.
Whena child is iil, he still needs nourishment.

Asick child needs food so that he can fight infections without using up all the nutrient reserves.

in his body.

However, he may lose his appetite and may refuse to eat, but he needs strength 55 (0 get better from iliness.

Time and care must be taken to help an ill child eat enough food.

Even if small amounts of food are eaten, this will heip if such feeding is repeated as often as possible.
Sometimes mothers mistakenly believe that a sick child should have little or no food.

The following advice may help a mother feed her child when heissick : — Breast-feeding should continue always even if the child’ has diarrhoea or vomiting, — Anadequate fluid intake is esse: ial when tnereis an infection.

Boiled water, coo!

weak tca, vegetable soup etc.

can be offered.

If there is diarrhoea, oral rehydration fivids should be given.
— Infections affect the appetite and sometimes a sick child has a sore mouth or lips.

He mignt be persuaded to eat if he is offered foods which are softer, non-irritating and more tempting than the usual diet.
Sick children should, therefore, be given small frequent meals of mixtures cf soft foods such as cereal porridge with boiled milk, khichri, bread or biscuit soaked in milk, non fibrous fruit such as banana, eggs and tender fish if culturally accepta- ble and could be afforded, — Makesurethatchildren with measies, diarrhoea and respiratory infection, eat plenty of vitamin ‘A’ rich foods.
In vitamin ‘A’ deficiency areas the massive dose of vitamin ‘A’ could also be given to such children in.consul- tation with the health personnel.

— When a child is recovering, give him a well balanced diet with sufficient energy, protein and other nutrients to enable him to catch up growth and replacement of nutrients stores.

The nutrient intake of the child after illness can be easily increased by increasing one or two meals in his daily diet fora peniod of about a month or so.
How to make sure that foods for infants are clean and safe : Personal hygiene plays an important role in feeding infants.

If cleanliness is nolobserved, supplementary feeding may do more harm than good to the child by introducing infections to the infant.

It is, therefore, important that all foods prepared for young infants are handled in a way that they are free from any germs.
Some of the considerations while preparing foods for infants are as uncer : — Hands should be washed with soap and water before handling the food as germs that cannot be seen in dirty hands can be passed on to the food.

— Utensils used should be scrubbed, washed well, dried and kept covered, Utensils uSed for feeding should be boiled, if possible.

— Cooking kills most germs.

The foods prepared for infants should be cooked property so as to destroy harmful bacteria present, if any.
— After cooking, handle the food as littie as possible and keep it in a covered container protected from dust and flies.

— Cocked foods should not be kept for more than one to two hours in hot climates unless there is a facility to store them at refrigeration temperature.
— The hands of both mother and chiid should be washed before feeding the child: Utilising the available nutrition and health services : There are a number of nutrition and health services available {cr young children in almost all places.

The people in the community should be informed 56 about various services which are available for children in the ‘village, at the sub-centre, at the Primary Health Centre, under Maternal and Child Heaith Services, Integrated Child Care Services etc.
Every effort should be made to encourage the community members to make use of these facilities so as to promote child health Preparation of some supplementary Foods for infants 1.

PAUSHTIK DALIA Ingredients .

50 8, 25 द.

30 g. 100 g. 15 ६ 5g Wheat Dalia Moong Dal Carrot Milk Sugar Fat Method / 1.

2.

Pick and roast wheat dalia in fat.

Add washed moong dal.

grated carrots and about 1'4 glass of water and cook till soft.

Add sugar and milk and cook for a while.

3.

2.


GHUNGUNI DALIA Wheat whole Moong (whole) Sugar Milk Fat/Oil 20 g. 20 g. 15 9; 100 g. 5g.

Method : 1.

Pick, wash and soak wheat and whole moong overnight Tie in.a wet musiin cloth and keep aside till half inch sprouts appear.

Grind the sprouted wheat and moong into a coarse paste.

Heat fat.

Fry the paste for a while.

Add about one cup of water and cook for 5 minutes.

Add sugarand milk and mix.

७ ( ० ५ 5.


3, LEAFY KHICHERI Ingredients : Rice Moongdal Spinach Roasted groundnuts/ Til (gingelly seeds) Salt 50 g. 40 4.

100 5 18g.

to taste.

Method : 1.

2, 3, Pick, wash and soak rice and dal for half an nour.

Wash’spinach thoroughly and chop finely.

Cook all the ingredients with sait in just sufficient water.

NOTE: For young infants, the khicheri can be passed through a sieve to get a4 smooth semi-solid paste.

57 4.

WHEAT BESAN HALWA : lngredients .


Wheat flour Besan Fat/oil Water Sugar 25 g. 25 g. 10g.

as required 25 g. Method : 1.

2.

4.

4 Roast wheat flour and besan separately.

Heat fat or oil, add wheat flour & besan and roast for a while, Add sugar and water and cook stirring constantly.

When ail the water dries up and halwa leaves the sides of the Karahi, remove from fire.

5.

CEREAL PULSE VEGETABLE SOUP : Ingredients , Rice Lentil Potato Carrot Tomato Sait Ghee/Vanaspati 10 g. 10g.

20 0.
20 0.

30 g. 30 g. to taste 54.

Method ; 1, 2.

3.

4.

5.

6 Pick, wash and soak rice and dal for half an hour.

Peel potatoes and scrape carrot.

Chop all the vegetabies: Cook rice, dal and vegetables in sufficient water with salt till soft.

Mash and pass through a sieve to get a thick soup.

Add hot ghee or vanaspati.

SPINACH-TOMOTO SOUP : Ingreaients : Spinach Tomatoes Rice 58॥ Ghee/vanaspati Method : 1.

2.

3.

4.

5.

Wash and soak rice for half an hour.


Wash spinach thoroughly, Cook vegetables and rice with salt in sufficient water till-soft.

Mash and pass through a sieve to get a thick soup.

Add vanaspati or ghee.

hi LAPS!

; Ingredients : Wheat Flour Besan Jagaery Water Ghee/Vanaspati 58 100 g. 100 g. 20 ५.

A pinch, 54.

30 g. 20g.

30 g. 200 4.

50, Method: 1.

2.

Roast wheat flour and besan separately.

Add warm water gradually and cook stirring constantly so that Jumps are not formed.
Add jaggery and mix.

Add ghee/vanaspati 3.

4.

PREPARATION OF INSTANT INFANT FOODS 8.

RICE PULSE MIX: Ingredients : Puffed rice (Murmura) Roasted bengal gram Roasted groundnuts Method : 1.

Remove the skin of roasted bengal gram and ground nuts, 2.

Grind all the ingredients separately into a fine powder, mix well.

3.

Store in air tight containers.

9.

RAGIMALTED FOOD Ingredient: Ragi Roasted Greengram dal (or any other dal) Roasted Groundnuts Roasted Gingelly (Til) Seeds 1 kg.
500 g. 200 g. 900 g. 400 g. 200 g. 100 g. Method : 1.

2.

Soak ragi in water overnight.

Drain the water, spread the grains on a plate and allow to germinate by covering with a damp cloth for one day.

Dry the germinated ragi in the sun and roast till flavour.

Powder all the roasted ingredients individually, mix and store in air-tight it develops a malted 3.

4. containers.

10.
4. containers.

10.

WHEAT MIX: Ingredients ; Whole wheat Greengram dal washed Roasted groundnut Method : 1, Roast wheat and dal separately in hot sand, 2, Remove the red skin of groundnuts.

3.

Grind all the roasted ingredients and mix well.

4.

Store in dry, air tight containers.

1,0 kg.

600 gms.

250 gms.


Note : For feeding, take three tablespoonfuls of any of the instant infant ‘oods (recipes 8, 9 & 10) and mix with a small amount of boiled and slightly cooled water to make a porridge like food for infant.

Add sugar or jaggery.

Milk can also be added if available, The instant food can also be added to dal or gravy and fed to the child.
59 Chapter-9 NUTRITIONAL NEEDS OF CHILDREN The first and the foremost requirement for the growth of children is adequte nutrition, While it is important throughout childhood, it is more crucial during tne first 5 years of life when rapid growth is occuring and the child is entirely dependent on his mother for food.
Insufficient food not only results in under nutrition and growth retardation, but also affects the learning capacity of a school going child thus depriving him from the full benefits of education.

Further, if the nutritional needs are not fulfilled after the child has reached puberty, his or her health will be grossly affected preventing him/her from development into his/her full potentials.
The nutritional needs of pre-school children (1-5 years), school childern (6-12 years) and adolescents (13-18 years) are discussed in this chapter under following sub-heads: — Importance of nutrition for pre-schoolers.

— Meeting the nutritional.

needs of pre-school children.

— Ensuring adequate nutrient intake by school children.

— Increased needs of adolescents.


— Heights and weights of normal Indian children, importance of nutrition for pre-schoolers : The pre-school age is the most crucial period in achild’s life.

This is the period when the child increases his activity and is exposed to the environment outside the home.
It is, therefore, necessary that proper care is taken regarding the pre-school child's health, Providing a nutritious and wholesome diet and immunizing the child against diseases common during childhood are of utmost importance.

If nutritious food is not given to him, stunted growth will result and malnutrition will set in.

Malnutrition in early life affects his developent in later life.
Pre-school children are extremely vulnerable They succumb readily to infec- tions particularly when their diets are inadequate both quantitatively and qualit- atively.

Several studies have shown that the diets of pre-school children are deficient in energy, protein, vitamin ‘A' riboflavin and iron, Thus, almost all the major nutritional problems such as: protein-energy malnutrition, vitamin ‘A’ deficiency, iron deficiency anaemia etc.

are common in this age group.


Even when malnutrition is not severe, pre-school children suffer from varying 60 ren against common childhood diseases such as tuberculosis, polio, diphthe- ria, whooping cough, tetanus and measles has been discussed in chapter 13.

Ensuring Adequate Nutrient Intake by School Children : - School going children continue to grow rapidly.

Besides their increased requirements of nutrients per kilogram of body weight, they are subjected toa lot of stress and strain of education.
Schoo!

work, class competitons and other emotional stresses may affect their appetite thus reducing their intake further.

The nutrition of schoo!

going children is, therefore, important both for their physical growth and development, and for enabling them to absorb lessons in the class.

Neglecting the nutritional needs of aschool going child will affect his power of mental concentration adversely thus depriving him from the full benefits of schooling.
The diets of school going children have been found to be deficient in almost all the important nutrients such as energy, protein,vitamin ‘A’, iron etc.

One of the important reasons for their poor intake is their long hours of schooling without adequate food intake during school hours.

The packed lunches carried by them are usually not adequate both in quantity and quality.
Thus,one of the important ways of ensuring adequate intake by school going children is to give due importance to their packed lunches.

Some of the examples of nutritionally balanced packed lunches are : 1. oil) Paushtik roti (wheat, besan, leafy vegetable’ + Pudina Chutney Seasonal fruit — gauva/banana/mango 2, Vegetable stuffed parantha Sprouted moong chat Carrot 3.

Rice-dal cheela.

Potato subji.

Groundnut Chikki 4.

Sprouted Moong Sandwiches Tomato/Cucumber 5.


Broken-wneat pulao (Dalia, Sprouted dal & vegetable) Chana-murmura laddoo.

Increased Needs of Adolescents : Adolescence is the period during which a child grows into an adult man ora woman, Adolescents are those in their teens, starting from around 10th to 12th year, adolescence fasts till the age of 18-20 years, Itis a vital period.in a person's life because the body develops fast and this is the last chance to grow well and to be weil built.
Usually, during the early stages of adolescence, the individual has a very high growth spurt, which slows down later.

Apart from physical growth, several changes take place during adolescence, for instance the persqn attains puberty.

Besides adolescents have some emotional disturbances at this stage.
Because of this stress and strain, the adolescent may tend to give little attention to his/her diet, It Is, therefore, important that a teenager gets his nutritional requirements for proper growth and development.

It may, however, be remembered that growth spurt and secondary sex characteristics appear earlier in some children than in others.
Therefore, one need not be unduly disturbed at any late ocdurrence of these events in any individual, unless the retardation is very obvious, 61 ५ degrees of growth retardation, This stunting at the crucial growing period can heve a lasting impact on the physica!

stature of the individual Meeting the Nutritional Needs of Pre-school Children : For the proper growth of the pre-school child, it is necessary that his die!
contains cereals, pulses, vegetables, milk, oils, and sugar or jaggery in neces- sary quantities.

A cereal pulse mixture like rice and dal, khicheri or idliis a traditional food for young children in many communities.

Such foods should be encouraged.

These foods could be further improved by the addition of vegetables, particularly red, orange or green coloured, into them, Children who do not eat flesh foods and eggs should be given more quantities of dal and if possible, more of milk and milk products.
Exposure to sunshine Is one af the best ways of getting enough vitamin 'D', Encourage young children to play in the sun for at least an hour per day.

Cleanliness in feeding the child is very essential.
Besides maintaining high standards of hygiene during handling and preparation of food, and feeding, children should be helped todevelop good hygienic habits particularly during meal times such as washing hands before eating, cleaning mouth after meals and so on, The nutritional requirements of young children are much higher than those of adults when compared on per kilogram body weight basis.

But smail children cannot eat bulky meals at a time.
Care is, therefore, necessary to ensure that foods of right quantity and quality are prepared in proper consistency for young children.

Addition of fat or oil to his food is extremely important as it increases the energy value of food without increasing its bulk.

Nutritious snacks like laddoos, peanut brittie, matharies etc.

which could be prepared and stored fora fortnight orso, given in between the three major meals help to ensure adequate intake of nutrients by the child.
The quantities of foodstuffs required for balanced diets for pre-schoolers, school going children and adolescents are given in the following table : BALANCED DIETS FOR CHILDREN AND ADOLESCENTS Food Items Children Boys Girls (in graurs) 1-3 4-6 years.

7-9 i, 13-15 16-18|10-12 13-15 16-18 years years Cereals Pulses Leafy Veg.

Other Veg.

Roots & Tubers Milk Oil & Fat Sugar or Jaggery 175 35 40 20 10 300 $8 30 270 i 420 45 40!

35 50 :50| 50 50 40) 30 3 25) 20 250 250] 250 40 30| 25 45 40!
40 475 50 40 60 50 200 40 45 520] 50) 40} 70; 8601 200| 45) 351 380 45 SO 50 30 250 3 45 400 45 50 50 30 200 35 45 44) 45 100 40 50 150 25 20 During pre-school years, for proper growth of the child, not only ts diet important but the child should be given the necessary immunizations to protect him from diseases common during childhood-immunizationof child- 62 The nutritional needs of adolescents are comparatively much higher than other children.
They have good appetite which should be normally satisfied with foods of high nutritional value, Good nutrition during adolescence is important because of the twin demands of activity and body growth.

Teenagers should take enough of energy foods, body building foods and protective foods.

During this period, the nutritional demands of boys and girls are different.
With the attainment of menarche, girls incur blood loss which must be made good by supplementing their diet with iron rich foods such as green leafy vegetables.

In fact, the intake of green leafy vegetables of both boys and girls has to be increased because of the increase in bicod volume, Milk should be an essential ‘dietary item or else the calcium needs will have to be met through consumption of ragi or other foods rich in calcium.
Nibbting, intake of empty calories through soft drinks and dieting should be discouraged, Heights and Weights of Normal Indian Children : The physical growth of children can be monitored by the measurement of body height and weight and making a comparison with the height and weight of normal Indian child of that age.

The heights and weights of normal Indian children are, therefore, given in the following table: HEIGHTS AND WEIGHTS OF NORMAL INDIAN CHILDREN Age Yrs.

BOYS Height Cms.

Weight Kg.


 53:25 56.00 63 GIRLS Height Cms.

Weight Kg.
Weight Kg.

 Age Yrs 1.0 1.5 2.0 25 3.0 3.5 40 45 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0 15.0 16.0 17,0 Chapter-10 GROWTH MONITORING Measuring and monitoring the growth of a child is essential for revealing the nutritional development during the early life.
Measurement of weight, it’s recording, interpretation of growth chart etc.

are important aspects to be learnt for growth monitoring.

Various aspects of growth monitoring have been dis- cussed under the following sub-heads : — Importance of growth monitoring.

— Ways of measuring growth.

— How to weigh accurately and record on the growth chart.

— Interpretation of the growth chart.

— Mid-arm circumference measurement.

importance of growth Monitoring : Every child needs to be a healthy child.
To be heaithy, a child must have enough of the right kind of food so that he can grow properly.

If he does not eat well or has repeated attacks of infection, he will not grow well and will be lighter in weight than what he should be at his age.

Thus the child will not be healthy.

So by measuring growth we can know if the child is healthy.

When this is done repeatedly it is called growth monitoring.

Ways of measuring growth : There are different ways of measuring growth.
The simplest and the most commonly used are the “weight for age” and "Mid-arm circumference tape.” Other measures include weight for height,chest circumference, head cir- cumference etc.

Weight for age : As the child grows, his weight also increases.

Thus by weighing a child regularly and comparing it with the standard weight for that age, we can know 64 whether the child is growing well or not.

There are two factors in measuring growth — weight and age.
Determining the age : It is very important to know the age of the child correctly.

In situations when the mother does not remember the date of birth of the child, then it can be found out by relating the time of his birth to : — Important events in the village e.g.

election, drought, flood.

— Important festivals e.g.

Diwali, Id, Teej etc.

— Important days as Purnima, Amavasya.

— Important events in the household e.g.

marriage or death.
marriage or death.

In @ particular area, a calender relating to the dates of the important events can be kept ready for easy reference.

How to weigh the Child accurately and record on the Growth Chart: After determining the age of the child the next step is to weigh the child.

There are two main types of weighing scales — beam balance and spring balance.

Beam balances are the scales used in the market.

They.

are accurate but are heavy and cannot be moved from place to place.
A spring balance is much lighter, can be easily carried and fixed on a beam in the house orto a branch ofa tree strong enough to hold the child.

FIG.

1 TWO TYPES OF BEAM BALANCE FIG.

2A SPRING BALANCE : Steps in weighing the child.

— Suspend the scales (when the spring balance is used) from a hook or a beam, so that it does not touch any wall — The needle should be on zero before the child is weighed.
If not, then necessary adjustment has to be made: 65 i 3 x a ा ् क ् ‍ ् ल े ड ब M S I S H L O H V Y L S Y O W d i D “ “ d H a / g n i g e u a c s e m o v E ) l l u ४ ॥ ७ ० 1 ० / | ७ ० ४ ६ ७ 9 १ ७ s A I W ५ / ० 1 5 ५ 3 ० 1 8 5 1 ६ ४ 9 ० 1 ० # # , ₹ S W O ० ० ३ ० ० # छ % + र ् प 0 ५ s e e w १ ० ० ० ० 7 ० ॥ # / ॥ ॥ 1 9 8 ७ , e O Y H a — The child should be placed in the sling with the minimum clothes possible.
— Read the weight to the nearest marking taking care to see that the child's feet are not touching the ground or any other surface.

— Record the weight and subseqently plot on the growth chart.

Interpretation of the Growth Chart or Road to Health card: The growth chart is applicable for children from birth to 5 years.

From a growth chart we can determine whether-the child is healthy or needs special care.

The growth chart enables us to compare the weight for thatage.(i.e.
compare the weight with that of a healthy child of the same age).

The horizontal lines represent the weight In kgs.

while the vertical lines represent the age in months.

The boxes at the bottom of the card are for the months and the first box records the month when the chiid is born e.g.

if child is born in March it will be recorded as shown in Figure 3.

The top two lines indicate the general direction of growth in healthy children.

These are also called the 'reference lines’ or ‘the Road to Health’.
Thus, if a particular child's weight for his age falls between the two top tines, then he is healthy and if below the 2nd line then he is mainourished, Below these lines are 3 more lines which classify the extent ta which the.child is suffering from malnutrition — Grade |, Grade ||, Grade III and Grade IV.
These have been arrived at by determining the percentage to which the-weight is below that of the standard, Back side of the growth chart is used to record other information like the particulars of the family, Immunization, Medical history etc.

To plot the weight on the growth chart, we look for the line corresponding to his age at the bottom of the graph, We follow this line up to the point where the weight line as determined by the present weight cuts across.
This point represents the point for this particular child.

e.g.

if the child is 1 year and 3 months & weighs 8.3 kg, his point on the growth chart will be X, (Fig.

3).

The position of the dot within a column can be adjusted depending on whether the weight is being taken in the early, middle or end of the month.

Subsequent weights of the child taken on the corresponding dates are recorded on the same card.

By joining the points we know how well the child is growing.
If the line is moving upwards, it indicates that child is growing and if itis horizontal or coming down then itis.a cause for concern.

!tis important to see the general directions of the growth line rather than the individual point.

Examples : a, A.

This indicates that the child is growing well.

Even though the weight may have fallen at some stage (point x) but the overall trend is upwards and hence it is Qood, 67 s e P B.
The line is almost at the same level indicating that due to some reason the child has stopped growing.

Attention has to be given to this child.

C. The line has a downward trend showing that child is loosing weight and hence needs attention.

The weight for age graph has three important uses : \, To see how well or badly nourished the child is at particular point of time.

2.

To see that he is gaining weight and growing well.

3.
3.

The card, it explained to the mother, can help her to monitor her own child’s growth.

Mid arm circumference measurement : Another method of determining the heaithy status of the child, isthe midarm circumference.

The measurement around the middle of the upper arm (1.6. between the shoulder and elbow) is called mid arm circumfererice.

The circum- ference is almost the same between the age of 1 to 6 years and gets reduced if the child is malnourished.
|f the measure is above 13.5 cm; then the child is healthy and between 12.5 and 13,5 cm.

indicates that the child is a boderline case and below 12.5 cm.

he is definitely malnourished.

The tape for mea- surement is generally of two types: 1.

Graduated and therefore, gives the exact reading e.g.

12.8.cm.

or 14.1 cm.

etc.

2.

Coloured tape in which the area before 12.5 cm.

is coloured red, between 12.5to 13.5cm.

as yellow and after 13.5 cm.


as green, thereby indicating ata glance whether the child is healthy.

गम Yellow Green 0 12.5 cm.

13.5 cm.

Above 13.5 cm Thus, if the edge of the strip, when put around mid arm touches the green part, ‘then the child is healthy, if the yellow part then he is a border line case and if the red part then he is definitely mainourished.

Steps in measurement Rest the bare left arm loosely against the side of the body.

1.

2.
1.

2.

Place the tape around the middle of the child's left upper arm.

3.

See the colour against which the edge of the tape comes across and deter- mine the nutritional status of the child as mentioned above.

Please note that the tape can only be used for children between 1-6 years.
This is a quick method of determining mainutrition in children, Other measurements : Weight for height, chest and head circumference could aiso be used in the similar manner as explained for weight for age and mid-arm circumference.

Growth monitoring charts and tapes can be made and used to measure the nutritional development.

68 — — — Chapter-11_.


COMMON NUTRITIONAL DEFICIENCY DISEASES Some of the nutritional deficienay diseases commonly seen in our country are Protein-Energy Malnutrition, Vitamin ‘A’ Deficiency, Anaemia and Goitre.

In order to recognize the type of malnutrition, to give proper advice and prevent serious consequences, the common nutritional deficiences are discussed under the following sub-heads : Protein Energy Malnutrition — What is protein-energy Malnutrition ?
— Identifying children with Protein-Energy Malnutrition — Causes of Protein-Energy Malnutrition — Management of children suffering from Protein-Energy Malnutrition.

Vitamin ‘A’ Deficiency — Identifying children with Vitamin ‘A’ Deficiency.

— Treatment and Prevention of Vitamin ‘A’ Deficiency, Anaemia — Identifying children with Anaemia, — Causes of Anaemia.

— Treatment and Prevention of Anaemia.


Goitre What Is Protein-Energy Malnutrition : Protein-energy malnutrition is number one nutrition problem in the country.

Itaffects mainly the child population specially in the age-groupof 0 to 5 years.

It is a very common condition among children under 5 years of age in poor communities, 4 out of 5 young children have some degree of this malnutrition while one out of 10 may be seriously affected by it.
Children with such malnutri- tion have a much higher death rate than adequately nourished children.

Protein-energy malnutrition and infectious diseases often occur together.

Protein-energy malnutrition occurs when there is not enough protein and energy, the two important nutrients, in the diet.

Energy deficiency is more common and important because when the diet is adequate in energy, It usually contains enough protein.
The pre-school child (child below § years) adjusts to mild and moderate forms of protein-energy malnutrition by stunting its growth, 69 Butif the food gap is wide and the shortage of energy and protein derived from the diet is acute for a prolonged period, the position then becomes rather serious.

A child with a servere protein-energy mainutfrition may weigh less than 60% of the expected weight for age, Such children show gross signs of disease.
The severe protein-energy mainutrition can take two forms — ‘Marasmus’ and ikwashiorkor, Some children may show extreme muscle wasting and are reduced to just skin and bones.

This condition is known as ‘merasmus’, The others may retain water in the body causing swelling of fore-arms, hands, legs and feet.

Such children are said to suffer from ‘Kwashiorkor’.

The term 'Kwa- shiorkor' means the sickness a child developes when another baby is born.
The severe forms of protein-energy malnutrition are so linked that changing cir- cumstances can result into a transition from one clinical picture to another, For example, a child with early kwashiorkor can get marasmus by severe infective diarrhoea while an infant who got marasmus due to inadequate breast-feeding may get kwashiorkor during the second year of life when some carbohydrates foods are given.
Sometimes a child may show symptoms of both marasmus and Kwashiorkor, for example his face, Upper arms and chest may be showing extreme muscle wasting while the fore-arms and fore-legs may be swollen due to Oedema.

Such children are said to suffer from ‘marasmic-kwashiorkor’.

Generally,we see only mild and moderate forms of protein energy malnutri- tion than the advanced syndromes.

The root cause for all these conditions is the same i.e.
the child has been exposed to severe malnutrition for a pro- longed period.

child.

Figure-1; Characteristics of the underweight child.
Normat sa wmetas=sescce t~—— Shorter under weight -——— than normal ia more often & more severely identifying Children with Protein-energy Malnutrition : It is important to identify children with protein-energy malnutrition at the earliest, possible stage in order to cure them more effectively, 70 Fig 2b A child with Kwashiorkor The first sign of हे forms of protein-energy mainutrition is growth failure or growth retardation.
Weeks or months before a child looks like a case of matnu- trition, he would have stopped growing.

Children at 18 months may weigh no more than they did at9 months if the shortages of protein and energy have been pronounced in their diets, Growth failure can be seen most clearly at a child's growth chart.

Weighing the child regularly is, therefore, an important means for recognising early malnutrition.

When a child has been malnourished for along time, the growth failure can be seen in several ways.
He will not only be thinner (wasted), but also shorter (stunted) than a normal child of the same age (Figure-!

), Growth failure is the earliest sign of protein-energy malnutrition and the cases of malnutrition should be identified at this early stage when there is growth failure, Muscle Wasting : Muscle wasting is a constant feature of protein-energy malnutrition.
A child with kwashiorko: may retain some subcutaneous fat but ina marasmic child there is no fat under the skin, There are loose folds of skin over the arms, legs and buttocks.

The muscles are wasted and as aresultthe arms and legs are thin and all the bones stand out.

The abdomen is distended partly because the abdominal muscles are weak.

The face is also wrinkled and the bones stand out.


The child look like a “Little old man Oedema : (body swelling) is a constant teatue of kwashiorkor and with that only the disease is diagnosed, The swelling should, therefore, be tested over the front of the lower leg bone.

Press with your thumb for half-a-minute.

There will be a hollow depression when thumb is removed.

This does not happen in a healthy child who is just fat.

There may be swelling of the fore-arms, hands, legs and feet.
The face, abdomen and genitals may also be swollen.

It is possible to make a mistake and think that these children are fat.

The child may have a swollen puffy face giving an appearance of the “Moon face”, Though oedemais always there in kwashiorkor, it may not be all over the body, It may be confined to lower extremities only.

In some cases, there is wasting of the upper half and oedema in the lower half as in the case of marasmic-kwashiorkor.
Protein-energy malnutrition also makes a child inactive and irritable, He is dull and withdrawn and makes few attempts to walk or move about.

The mental apathy and refusal to food is more common jn Kwashiorkor than in Marasmus.

Sometimes one can detect protein-energy malnutrition due to changes in hair.

The hair become light in colour, i.e.

pale, brownish, orange or blonde.

The flag signi.e patchesofdark and lightcolouredhair insome childrenindicates their malnutrition status in the past.
The proximal part of the hairis usually light brown in colour.

The hair is often sparse and can be pulled out easily, The hair changas are more pronounced in Kwashiorkor than in.

Marasmus.

Some child with kwashiorkor have abnormal skin changes.

The skin is often paler than normal, and may become broken and appear like a burn.

There may be cracks in the skin-over the legs, buttocks and perineal areas.
Sometimes the skin peels off in small pieces like an old paint giving an appearance of flaky paint rash.

Protein-energy malnutrition is often associated with other deficiency dis- eases including infections.

Deficiency of Vitamin ‘A’ and Anaemia are com- monly seen among such children.
Protein-energy malnutrition is mainly found in pre-school children and In that, specially in montns, Marasmus is seen most commonly in the first year of life and is invariably due to failure of breast-feeding due to some reason or the other, Kwashiorkor occurs at a later the age group of6 to48 74 3 age than Marasmus, often in children of 18 to 40 months old.
This is usually during the weaning and the post-weaning periods The signs of protein-energy matnutrition i.e, wasting, swelling, changes in skin and hair etc.

are all quite easy to observe (Fig.

2).

It must, however, be remembered that the most important and early sign of protein-energy malnu- trition is growth failure.

Regular weighing of children is, therefore, the best way to detect protein-energy mainutrition at an early stage.
Causes of Protein-energy malnutrition : Protein-energy malnutrition is caused by a number of complex and closely related factors which relate to the social and economic conditions of the family Some of these factors are poverty, ignorance, superstition, lack of food, inade- quate hygiene (!ack of cleanliness), occurrence of infectious diseases in the area where the family lives.
These factors either singly or in combination are the pre-disposing factors either singly or in combination are the pre- disposing factors to protein-energy malnutrition, The main cause, however, is poor in-take of food aggravated by an infection such as gastro-enteritis, measles or respiratory infection, There are certain factors, specially in the feeding of children, which contribute to protein-energy malnutrition such as: — Failure of breast-feeding due to death of mother or chronic disease of the mother or inadequate secretion leading to marasmus.
— Late introduction of supplementary foods.

— Inappropriate choice of supplementary foods due to ignorance or traditional beliefs.

— Unhygienic feeding habits which pre-disposes a child to diarrhoea.

— Withholding of foods in an attempt to cure diarrhoea.

— Poverty and inability to buy foods due to high cost.

— Poor care of children by their siblings when their mother is away at work.
— Neglect of smaller children in large families where the mother has too-much work, — Stoppage of breast-feeding for the first child due to short interval between the two.

children.

— Twins receiving only half as much milk and attention from the mother than as a single baby, The risk of protein-energy malnutrition is great between the ages of 6 months and 48 months because the child is growing fast and his food habits are in a transitional stage.
In some communities, boys are valued more than girls for social and economic reasons and as such girls may be consciously or uncons- ciously neglected.

Babies who were born small have not had enough nourish- ment in their mothers womb.

Many of them become malnourished since special care required by such babies is usually not given.

The peor growth in the first few months can be judged by weighing the child regularly.

A child should gain at least 500 gms.

per month in the first three months of life.


Many children who gain less weight become malnourished.

There may be anumber of reasons for this but the most important is the mother's failure to breast-feed.

Stoppage of breast-feeding may be inevitable if the mother dies soon after the baby is born.

But sometimes the mothers stop the breast-feeding because of the false belief that bottle feeding is modern and, therefore, good.
Where both mother and father have to go out to work, their small baby is left at home without breast- feeding or any alternative food for the period the mother is away.

Since the baby does not suck frequently enough at the mother's breasts, the mother's no!

74 producing enough milk.


Besides, the family has some wrong beliefs (supersti- tions) about feeding any solid food to the child until he is one year old, The parents are ignorant about immunizations, As a result the baby is not getting enough breast-milk or any other alternative food, heis left alone without his mother, and he is not receiving any immunization.

Insuchconditionsa field level worker can do a number of things to reverse the effects of poverty, superstition and ignorance on this:child.
The delay in introducing additionai food is one of the important causes of protein-energy malnutrition.

Though breast-milk is best and should be given upto 2 years of age, other foods should be added after the age of 4-5 months and increased in amountas the child grows older.

If this is not done, growth will slow down and this may be the start of malnutrition.

Infectious diseases specially repeated Diarrhoea, Whooping cough, or mea- sles contribute significantly in causing protein-energy malnutrition.
Firstly, there is damage due to these diseases themselves, to their wrong treatmentand secondly due to lack of food because it is often wrongly thought thata sick child should eat less frequently than a normal child.

The risk factors in different communities may vary.

A field level worker should, therefore, study the background factors in the families of malnourished children in order to ascertain the specific causes of malnutrition ina particular area.
Management of Children suffering from Protein-Energy Malnutrition : A field level worker can help most children with mild or moderate protein- energy malnutrition.

In fact two groups of children need special help from the fieid level worker, The first — children at risk of developing protein-energy malnutrition, and the second — the children already suffering from protein- energy malnutrition.
They can be identified by regularly visiting the homes of high risk families, by observing growth curves of children, and by examining children with infectious diseases like measles and diarrhoea.

Modification and improvement of diet is the method which can be used to manage protein-energy malnutrition.

Thisis also called nutrition rehabilitation, But it will fail unless the family, and specially the mother of the child, cooperates actively.
Convincing the parents that a modified diet is essential for the child is the main task of the field level workers.

A field level worker may know what food a child should eat, but the mother must also believe in this and must be willing to make the best use of foods available to the family.

Involving the family in the process of recovery is the best way to teach about mainutrition and prevent its recurrence.
Parents can learn about better nutrition only by seeing their child- ren recovering and becoming healthy by better feeding.

Children suftering from protein-energy mainutrition need high calorie and high protein diet.

In addition small amounts of foods of animal origin such as milk, egg, fish etc.

are also desirable, Nutritious supplements can be prepared at home using cereals, pulses, sugar or jaggery and oil.

The children may have to be pursuaded initially and if needed even forced to eat the diet.
But as they improve, the appetite return$ and no feeding problems will be experienced.

Some instructions for the better feeding of malnourished children are : — Increase the number of meafis per 08५ : The child, specially when not so well, is unable to conform to the adults feeding pattern of thrice a day.

It is, therefore, necessary to feed the chiid 75 with small frequent reeds.

This would also help the child to have more food.


— thcrease the variety of foods being given : An early symptom of PEM is loss of appetite.

Thus, the child needs persua- tion and variety.

Even the common family diet can give variety, Cereals, pulses, root vegetables and some leafy vegetables in different combinations and as different preparations can provide many varieties.

— Add fats or oils to the diet : One has to remember that calorie deficiency is a major hurdle in PEM.
Efforts should, therefore, be made to add calorie rich foods in substantial amounts.

This will not only increase the energy value of the diet, but will also make it tasty and acceptable and asa result, the child will eat more.
Properly cooked ‘Khicheri without spices and with the addition of some vegetable oil or butter is an excellent food to rehabilitate a malnourished child, — Encourage the mother to breast-feed the child ; If the mother is lactating, encourage her to breast-feed the child — but always after the child has taken some solid food.

— If possible, give some foods which come from animals : Ifthe family can afford,some animal food should be added to the child's diet.
Even smail amounts of milk, egg, meat or fish will help a malnourished child recover rapidly.

However, these foods are not essential.

Vegetable based diet with the addition of mother's milk can be quite adequate.

— Do not stop feeding if there is diarrhoea : Diarrhoea is no reason to stop feeding.

Oral Rehydration Solution should be given to the child alongwith normal feeding to prevent the occurrence of dehydration.
— Give Instant Mix based on Cereal, Pulse and Oilseed : This consists of wheat, bengal gram, and groundnuts in 2: 1: 1 proportion.
The ingredients are roasted and powdered and stored in air tight containers, The mix is fed by reconstituting it with boiled water or milk and adding sugar or jaggery, The ingredients of the mix can be modified depending upon the local availability, The Mix can be fed to the child 3 to 4 times in a day, Such foods supplements can improve the child in a few week's time and com- pletely Cure in about 3 months, Better feeding can completely take care of mild and moderate protein-energy matnutrition cases and even the severe cases if there is no complication like tever, infection or other aggravating conditions.
The effects of better feeding can be very encouraging to both the parents and the worker.

This can be seen by reguiar weighing of the child.

Regular weighing ts a good way to know the progress of a mainourished child.

Some children particularly the ones suffering from severe protein-energy mainutrition need very special care because their lives are in danger.

These children should be referred to the supervisor or the health centre.
The children who need to be referred to the health centres are - 76 pe —— लक : | है (i) Children with severe malnutrition.

These include very wasted Marasmic or greatly swollen Kwashiorkor children who will not eat, (ii) Children with complications of mainutrition.

These include children with Anaemia and Vitamin ‘A’ deficiency and children with signs of infections, high fever, distressed breathing and repeated diarrhoea.

(iii) Children with moderate mainutrition who do not improve with better feed- ing.
These are children who have some infection which is difficult to diagnose, for example Tuberculosis.

Efforts should be made to encourage the community to make use of supple- mentary feeding programmes being implemented in the area.

Sometimes the community leaders and wealthy farmers can aiso be persuaded to provide food for such children.

Ultimately better results will depend on the education of the people in nutrition and related aspects in dealing with this problem.
Nutrition education regarding the supplementation of cereals with pulses in order to obtain good quality protein from the available resources is an important aspect.

Nutrition education of the mothers about the proper weaning of the child is also important.

The following points need to be emphasised : — Encourage breast-feeding.

— Introduce supplements at an early stage.

Teach proper methods of bottle feeding where bottle feeding is inevitable.
— Emphasise the use of cup and spoon feeding instead of bottle feeding.

— Types of supplements which can be given at various stages.

— Education regarding the preparation of Instant Infant foods at home.

VITAMIN ‘A’ DEFICIENCY Identifying Children with Vitamin ‘A’ Deficiency : It Vitamin ‘A’ is a nutrient which is specially important for the health of the eyes in small children.

is also needed for their normal physical growth and for building up resistance to disease.
The most dangerous consequence of this deficiency in early life is the total loss of vision, It is all the more unfortunate that Gisability occurs in pre-school children.

Blindness in children can result ina life time of misery.

Many blind children are neglected and become mainourished and die.

A field level functionary can do much to prevent this.

sad situation.

She can identify children suffering from early Vitamin ‘A’ deficiency and can recommend treatment.
She can prevent the occurrence of Vitarnin ‘A’ defi- ciency by giving suitable dietary advice The earliest sign of Vitamin ‘A’ deficiency is the inability to see in dim light This ts also known as night blindness.

A child suffering from this cannot see very well in the dark particularly in late evenings or in semi-darkness.

In some areas this disease is so common that there is a local name for it.

The next stage in Vitamin ‘A’ deficiency is dry and slightly rough eye-balls.
Normal eye-balls are moist, smooth and shining.

The condition of rough and dry eye-balls is called xerophthalmia, This is the early stage of Vitamin ‘A’ deficiency.

Later, foamy patches appear on the sides of the eye-balls.

These are calledBitot’s spots.But these spots are not very reliable signs of active Vitamin ‘A’ deticiency since these can persist even after treatment.

At the early stages, an improved diet can prevent serious damage to the eye.
itis, therefore, important for a field worker to detect Vitamin ‘A’ deficiency.

They can work closely with health workers in detecting the early signs until they are weil trained.

77 If Vitarnin ‘A’ deficiency is not treated at this stage, the black portion of the eye called cornea gets affected.

It becomes smoky and hazy and turns whitish.

In later stages, the eye-ball becomes soft and an ulcer may form resulting in holes in cornea.
The eye is absolutely red and the cornea finally bursts thus completely destroying the eye and causing permanent blindness.

This condi- tion is known as Keratomalacia and is irreversible.

Certain children are at special risk of Vitamin ‘A’ deficiency.

These include children with protein-energy malnutrition and children with certain infections particularly measles and Diarrhoea.

Measies affects many body tissues includ- ing the eyes.
Diarrhoea affects generai nutrition and also the absorption of Vitamin ‘A’from the bowel.

Vitamin ‘A’ deficiency often appears after measies or diarrhoea.

Therefore, if the field level worker knows as to who may develop the deficiency, she can act in time to prevent the disease, Figure-3.

Photograph of beautiful, healthy aye.

Figure-4.

Photograph of changes in the white of the eye.

Figure-5.

Photograph of changes in the black of the eye.

Figure-6.

Photograph of changes in the skin.


Treatment and Prevention of Vitamin ‘A’ Deficiency : Treatment of Vitamin ‘A’ deficiency : Vitamin ’A‘ deficiency shouid be treated urgently.

Xerophthalmia can develop from dry eyes and lead to total eye damage within a very few days.

Ifa child has dry eyes, the field level worker should act immediately.

— Arrange to give a massive oral dose of Vitamin ‘A’ (2,00,000 International Units) by mouth.
This form of Vitamin ‘A’ is absorbed nearly as fast as a dose of Vitamin ‘A’ in water given as an injection.

Health workers keep stocks of such Vitamin ‘A’.

— |f no Vitamin ‘A’ is available, take or send the child to the nearest Health Gentre.

— Teach the parents of children treated with Vitamin 'A’ for dry eyes, about prevention.

All children at risk of comeal destruction related to Vitamin 'A’ deficiency must be properly icentified.

These include those who already have evidence of corneal changes.
Such cases are medical emergency requiring prompt administration of massive doses of Vitamin ‘A’, which can be administered orally or parenterally.

Parenteral administration is preferred in all cases with active corneal involvement or where severe malnutrition or systemic illness might interfere with intestinal absorption.

Vitamin ‘A’ treatment schedule for active xerophthalmia is : — Arrange to give massive dose of Vitamin ‘A’ (2,00,000 IU) and send the child to the hospital.
— Next day, give Vitamin ‘A’ (2,00,000 IU).

— On 14th day, give Vitamin ‘A’ (2,00,000 IU) — Feed nutritious food including eggs, milk, beans, meat and cooking oil.

Prevention of Vitamin ‘A’ deficiency : The ultimate goal of prevention programme must be the required dietary intake of Vitamin ‘A’ and pro-Vitamin ‘A’ by vulnerable children, and the elimination of all forms of Vitamin ‘A’ deficiency.

This would mean that all 78 0 j a e w e O @ 5 vrs -.
Fig 6 Changes in the skin children should consume foods containing adequate quantity of Vitamin ‘A’ which will prevent the occurrence of any form of deficiency manifestations.

Since factors like availability of Vitamin ‘A’ rich foods, likes and dislikes of childrenforsuch foodsandother conditioningtactors havecertain amount of uncertainity in them, preventive measures should be evolved which can be effectively implemented and could greatly reduce the dangers of xerophthal- mia.
The three main categories of preventive measures are as follows : (1) Massive dose prophylaxis.

(ii) Fortification of food products.

(iii) Nutrition education and horticultural activities.

(i) Massive dose Prophylaxis : Vitamin ‘A’ in the dose of 2,00,000 1U produces sufficient liver stores and this can protect the individal for about 6 months.

If such a dose is given in the form of capsules or as liquid every 6 month, this will give continued protection.

The Govt.
The Govt.

of India is implementing this programme through its health infrastructure.

A field level functionary should, therefore, arrange to give a massive oral dose of vitamin ‘A’ (2,00,000 IU) to all pre-school children, Sometimes these large doses may cause headache, vomiting or fever for a short period in some children.

The effects, however, pass off quickly.

The child could however, be given half a tablet of aspirin and the mothers reassured.
It is desirble to indicate whether the dose has been given to the child or not on his growth chart because it is dangerous to give this massive dase of Vitamin ‘A’ more than once in six months, Capital ‘A’ could be written at the bottom of the column of the month in which the dose was given.

This would help in avoiding the risk of repeating the dose and would also indicate when the last dose was given and when the next dose is due.
(il) Fortification of food products : The hydrogenated (vanaspati like Dalda) fats commonly used by the masses are fortified with Vitamin ‘A’ and ‘D' under a Govt.

regulation since long.

Recently the Govt.

has taken up a programme of fortification of miik with Vitamin A’ with a view to prevent Vitamin A’ deficiency.

Mother Dairies, Delhi Milk Scheme and other Cooperative Dairies in States/Union Territories are fortifying their milk supplies with Vitamin ‘A’.
Efforts could, therefore, be made to educate the community to go in for fortified vanaspati and fortified milk wherever available.

(ill) Nutrition education and horticultural activites : This form of intervention is the most important one and has been in use for 4 long time.

“Eat green leafy vegetables for youreyes” is a slogan or a message in use for not less than 30 years.
Nutrition education for making the mothers use green leafy vegetables for their children was and is even now an important objective.

Such educational efforts achieve more importance when Vitamin ‘A’ deficiency is observed in areas where green leafy vegetables are in abundance.

Apparently, their use in children's diet is rather limited.

Their lack of use is due to dietary preferences and in some cases cultural tabboos.

Educational efforts are needed to overcome these barriers.
Vitamin 'A' as such is present only in foods of animal origin such as eggs, liver, 81 milk and fish liver oils.

But Vitamin ‘A’ can be made in the body from a compound called ‘carotene’ which is found in vegetables and fruits.
A lot of carotene is found in yellow, orange and red, vegetables and fruits, green leafy vegetables, and red palm, ltis, therefore, necessary to educate the mothers to feed their children cooked green leafy vegetables, for example spinach, ama- ranth leaves and others; yellow fruits like papaya and mango; and carrots to prevent Vitamin ‘A’ deficiency leading to blindness in their children.

It must be emphasised that the child needs these foods every day.
Since Vitamin ‘A’ deficiency during the first 5 years of life is very danger- ous, sufficient caution regarding diet and nutrition has to be taken right from the pregnancy as the new born brings with him in his liver stores of all important nutrients like Vitamin ‘A’ and iron.

A pregnant woman should, therefore, consume adequate foods rich in Vitamin ‘A’ (or carotane) such as green leafy vegetables, fruits like mango & papaya, milk and eggs if she can afford.
By daing so, she will help the foetus to store enough Vitamin A’ in the liver.

After the birth, the new born must be fed "colostrum" which Is the milk secreted during the first few days after the birth of the child, and this should not be wasted under any circumstances, Nature has provided this safeguard for the children as colostrum is very rich in Vitamin ‘A’ and Vitamin ‘A’ being a fat soluble Vitamin, it is stored in the liver for future use.
Mothers must be encouraged to breast-feed their children because the breast-milk provides Vitamin ‘A' to the child.

In fact the lactating mother should continue to consume foods rich in Vitamin ‘A' so that she can supply enough Vitamin 'A’ through breast-milk to the infant.

Once the infant is 4-6 months:old, he must be given food supplements containing Vitamin ‘A’.

Soft cooked carrots, green leafy vegetabies should be fedto the child.
Green leafy vegetable can in fact be cooked with the cereal and fed to the child.

Incorporation of some of these foods such as green leafy vegetables, carrots, papaya, mango, milk, eggs, meat etc.

in his daily diet will ensure that the child is not deficient in Vitamin ‘A’.

It is necessary to include some amount of fatin child's diet so as to increase the availability of Vitamin ‘A’ to the body since it is a fat soluble vitamin.
This would also help in laying the foundation for good habits so that when the child grows up he would not refuse to eat green leafy vegetables.

If the child can be thus protected upto 5 years, there will be no danger of his becoming permanently blind due to Vitamin 'A’ deficiency.

There is an absolute need for imparting nutrition education for the use of green leaty vegetables in all possible ways — person to person approach, group educational sessions and mass media techniques.
Such educational efforts should also include the production of such foods in ‘home gardens or ‘kitchen gardens’.

This will not only extend the availability of these fruits and vegetables to the families, but will also inspire children and other family members to consume the fruits and vegetables produced in their own gardens.
ANAEMIA Identifying Children with Anaemia : Nutritional anaemia is widespread among women of child bearing age and children, specialiy from the low income groups which form the major segment of the population, Though iron deficiency anaemia is the most important form of anaemia in India, deficiencies of folic acid and Vitamin B,, also contribute 82 जा Although the amount of iron content in even the most inadequate diet is considerably more than man's nutritional requirements, iron deficiency remains for this one of the most commonly seen nutritional deficiency.
The explanation lies in the poor bio-availability of much of the iron-in the present day diets.

The prevalence of iron deficiency is, therefore, a function of the bio-availability of iron in the average diet.

But the varying requirements for iron determine as to which members of the population are affected.
In this regard, infants and pre-school children are at special risk because of their increased requirements related to rapid growth, In addition, women need more iron than men because of the super-imposed requirements related to re-production, menstruation, pregnancy and lactation.

Iron deficiency can arise either due to inadequate intake or poor absorption of dietary iron or due to excessive losses of iron from the body.
In India low intakes and/or poor absorption of dietary iron play an important role in causing anaemia.

The dietary iron absorption from habitual diets consumed in India is quite low being only 2-3%.

These diets, particularly those of poor people, are rich in inhibitors of iron absorption like phytate and tannin but limiting in absorption promoters like Vitamin ‘C’ and calcium and hence have low iron availability.
Deleterious effects of anaemia include reduced working capacity, maternal deaths, premature deliveries, low birth weight babies, increased susceptibility to infections and many other abnormalities in various body functions.

Signs and Symptoms : Early tiresomeness, loss of appetite, breathlessness on exertion and giddi- ness are some of the symptoms of anaemia.
Pallor of the skin, and pigmenta- tion of the skin specially around the knuckles, the finger nails and the face are common signs of anaemia The tongue becomes pale, smooth and shiny and the mucous rnembrane of the eyes become pale due to lack of blood which is-a good indication of severe anaemia (Fig.

7).

This, however, is not applicable for people suffering from conjuctivitis or B Complex deficiency.

In severe anaemia the finger nails become spoon-shaped, a condition known as koilonychia (Fig.

8).
8).

First there is a brittleness and dryness of the nails, followed by flattening and finally spooning of the nails.

If a pregnant woman with severe anaemia is not treated, she may go into heart failure, leading to death.

Anaemia is one of the important causes of premature births and increased neonatal deaths.
Anaemia is a very common disease among poor children, A child with anaemia is less active than a normal child, He may be pale and the inside of his lower eye lids and lips will be pale, light pink or whitish instead of red.

In severe anaemia, the child may be breathless and may have some swelling of the face, body and limbs.

Causes of Anaemia: There are many possible causes of anaemia in children.
Some of these are : — Adiet deficient in iron rich foods : This is the most common cause of anaemia in children.

The body cannot make enough blood if itdoes not have enough iron, A growing child needs a 83 lot of iron.

Many a times, the main food of the child is milk | contains very little iron.

Besides, many children do not like the foods which are rich in iron such as green leafy vegetables.
— Loss of blood due to worm infestation : A child may become anaemic because of loss of blood due to worms in his intestines which suck the blood.

— Loss of blood due to malaria parasites : Anaemia may result from red blood cells being damaged in a number of ways.

Malaria parasites are one serious cause of damage to blood cells.

— Inadequate stores of iron in new born babies : Anaemia may also occur in babies if they start life with too small a store of iron.
Ifa mother is healthy in the last weeks of pregnancy she will pass on to the baby a store of iron.

If the mother is anaemic, she will not have much iron to pass on to the baby.
If the baby is born prematurely, he will not receive the store of iron, From the causes of anaemia, it is obvious that the children at risk of anaemia include those who are premature (born early), those with anaemic mothers, those who have been fed too long only on milk and those who have not been giver, a diet including iron containing foods.
Children who are not protected from parasites particularly malaria and hook-worm will develop anaemia, Treatment and Prevéntion of Anaemia : Treatment : — Adiet which is rich in iron containing foods like leafy vegetables is a good start, but is unlikely to provide a high enough dose of iron tor severe anaemia, — Iron tablets easily increase the intake of iron.

One tablet two to three times a day according to the severity of anaemia can be given to children.
Iron tablets should be taken with food as it may not be tolerated well on an empty stomach, The mothers should be warned that their children’s stools will be biack while they are taking iron tablets.

Iron tablets can cause harm if many tablets are taken at once.

It is, therefore, desirable to keep iron tablets and other medicines out of reach of children, preferably locked in cupboard.

— The severe cases of anaemia, where the patient is swollen, breathless and very pale, may require blood transfusion.
— Treatment of any cause of biood loss or damage is essential.

The possibility of malaria and hook-worm infestation should be thought of in any case of anaemia and treated accordingly.

It will be necessary to send such patients to a Health Centre or Hospital for diagnosis and treatment.

Prevention : Preventive measures against nutritional anaemia are directed against iron deficiency in the body, which is the pre-dominant cause of such anaemia.
Improving the diet in respect of iron absorption and reducing the pathological loss of iron are the two main thrusts.

Thus preventive measure can be described under the following categories : i) Nutrition education for improvement of dietary iron intake and absorption.

ii) iii) Food-Fortification, [ron supplementation.

Pale Tongue Fig 7 Some signs of Anaemia Oedema Fig 8 Some Signs of Anaemia iv) Prevention of iron loss.
\) Nutrition Education for improvement of dietary iron intake and absorption: Some of the instructions for the better feeding of the vuinerable groups are as under : — Agood diet during pregnancy is the foundation for prevention of anaemia.

This will build up the mother's iron supply so that she can pass on 4 full amount to her child in late pregnancy.

It will enhance full development of the child in the mother’s womb and decrease the chance of a premature birth.
Her diet should be rich in iron-containing foods-green leafy vegetables, pulses, whole grain cereals, and jaggery, If animal products are accepta- ble and can be afforded, eggs, meat, and liver can be given.

Pregnant women frequently need supplements of iron tablets in addition to good diet.

— Infants should be fed mixed foods along with breast feeding from about 4 to 6 months of age.

Supplementary foods prepared trom cereal, pulse and a leafy vegetable will provide enough iron to infant.
Leafy vegetables should be included while preparing khichri or soup for the child.

— Iron containing foods should be included in the diets of pre-school, schoo!

children and adolescents.

Children should be given leafy vegetable prepara- tions right from the early childhood so that they develop a taste for these foods and do not refuse to take them when they grow up.
Education of the people with respect to the requirements of iron for various age groups, iron content of common foods, sources of iron is an important aspect in the prevention of anaemia.

Many types of green leafy vegetables such as Palak, Amaranth, Fenugreek leaves.

Drumstick leaves etc.

are consumed all over the country and most of them are rich sources of iron, calcium, carotene (Vit.

A), Vitamin C, Riboflavin and folic acid.


These vegetables are, therefore, inexpensive source of many nutrients which are essential for growth and maintenance of normal health.

Steps should, therefore; be taken to encourage cultivation of green leafy vegetables in kitchen gardens and school gardens.

Consumption of such vegetables in adequate amounts specia'ly by pregnant and nursing mothers and by children should also be encouraged.
While propa- gating the use of green leafy vegetables, ways and means of incorporating these vegetables in the diet of different age groups should also be mentioned.

Besides the common recipes such as sag, bhujia, missi roti etc.

the green leafy vegeta- bles can be incorporated in soup, dal preparation, chutneys, raitas, snacks etc.
The green leafy vegetables can be given to infants in the form of a puree (mashed), Khicheri, dal soups etc, The traditional practice of sprouting cereals and pulses is nutritionally very significant.

Sprouting helps to increase the bio-availability of iron in the sprouted grains besides increasing the content of Vitamins of B Complex group and Vitamin 'C.

Sprouted grains can also be used in a number of ways such as chat, sandwiches, stuffed paranthas, bondas, bhujia etc.
Malting also brings about appreciable improvement in the bio-availability of iron from cereals.

For the prevention of anaemia.

a diet rich in iron is valuable.

Food stuffs that are rich in iron are green leaty vegetables, whole grain cereals, millets specially bajra and ragi.

Inclusion of about 50 gms.

of leafy vegetables in the daily diet meets a considerable portion of the iron requirement.
(ii) /ron Supplementation : This method is possibly the most widely used measure for overcoming iron 87 deficiency anaemia.

Vulnerable segments of the population, specially in areas with high prevalence of iron deficiency, are covered with iron supplementation.

The Govt.
The Govt.

of India has been implementing a prophylaxis programme against nutritional anaemia among mothers and children since the 4th Five Year Plan Tablets containing iron and folic acid are distributed through various MCH and Family Planning Centres in the country to pregnant women in their last trimes- ter of pregnancy.

A field level functionary can ensure that all pregnant women in the area are given these supplements.
Premature babies have inadequate iron stores and should be given small doses of iron in the first three months of life.

Suitable iron mixtures will have to be obtained for such babies from the Health Centres.

(tii) Food Fortification ; Another important way of providing additional iron toa population is through fortified foods.

Salt has been identified as the most appropriate vehicle for iron fortification in this country.
The Government of India is proposing to launch a national programme to combat anaemia by undertaking large scaie production of iron fortified salt.

To start with, the programme is being implemented in the State of Tamil Nadu as pilot project.

(iv) Prevention of tron Loss: In areas where intestinal parasites especially hook-worm are highly preval- ent, measures for their eradication should be considered as the first step in the prevention of iron deficiency anaemia.
Periodical deworming may have to be undertaken with the help of the health workers in such areas.

Alongwith this, measures for promoting the use of some form of foot-wear, use af latrines and improving the hygiene will also be necessary Malaria control measures can be undertaken.

Anti-malarial tablets, if in use can be given to the children and recorded on their growth charts.

Goitre: Goitre is caused by the deficiency of the mineral-jodine in the body.
lodineis needed for the production of a harmone called Thyroxine by the Thyroid gland located in the neck.

This harmone is essential for growth and mental develop- ment.

The thyroid gland utilises the iodine present in the food and water we consume for producing this harmone.

lodine is present mainly in the sea foods (for example fish, crab, prawn etc.

), It is also present in all foods grown on aland which is not devoid of this mineral.
In other words, if the soil is not deficient in iodine, all the fruits and vegetables grown there will have enough iodine.

Goitre is, therefore, commonly seen inthe areas which are far away from the sea and where the land is being constantly exposed to erosion by the flooding rain water, thus removing the iodine from the soil.

The sub-himalayan regions in extreme North are endemic for goitre, i.e.

goitre is present there always to a smaller or greater extent in large proportion of the population.
Recently, goitre has been found in more regions including plains such as parts of Maharashtra, Delhi etc.

When the diet is deficient in iodine, thyroid gland has to work harder to pick up the minute amounts of icdine present in the food and water consumed.
In 88 ह ै र स Fig 9 Goitre दर | this process, the gland increases in size and goitre is the name given to the enlargement of the thyroid qland (Fig 9), Apart from the sweiling in the neck, goitre results in several other healtt complications, It affects physical growth and mental development.

The off- springs of goitrous parents are prone to become cretins i.e.

dwarfs with retarded mental growth.

People with stunted growth and deaf-mutes are commonly seen inthe goitre areas.
Recently, the ill effects of lodine Deficiency are described as lodine Deticiency Disorders (IDD) Unlike other nutritional deficiencies which are primarily caused by adeficient diet, endemic goitre depends on the soil characteristics, which ultimately determine the level of iodine in water and foods in that area.

Thus, endemic goitre and the associated cretinism, cannot be prevented or treated by dietary manipulations.
The only way to overcome the problem is to introduce the deficient iodine into the body.

There are several methods by which this could be done.

The two commonly adopted methods are : (i) Salt lodisation (or salt iodination) in which todine compounds are mixed with common salt (ii) Injection of iodised oil (i) Salt lodisation : This is most commonly used measure and leastexpensive.

lodised salt looks, tastes and smells like ordinary salt.
Since salt is consumed daily by everyone in fairly constant amounts, it has been considered the most practical vehicle for iodine supplementation.

The Government of India launched the National Goitre Control] Programme sometime towards the end of the Second Five Year Plan Under this programme iodised salt is made available in areas where goitre is endemic with a view to control the lodine Deficiency Disorders, Potassium iodate (K1O.)
is usually chosen as the compound to be added to the salt owing to its stability, The quantity of iodine which is to be introduced into the body everyday, ranges between 150 to 400 micro-grams (calculated as iodine) depending on the degree of goitre endemicity.

The daily requirement of iodine is 150 micro-gram per day and in most parts of the worid, the average intake of common salt varies between 5 to 15 grams per person per day, though variation oceurs from one country to another.
Though this is an extremely efficient method for controlling endemic goitre andcretinism, the impact of such a method is hampered by various geographi- cal, economic and administrative obstacles.

In areas of high endemicity, the salt iodisation programmes should, therefore, be made compulsory, supported by legal provision with appropriate supervising and enforcement agencies.

(ii) Injection of iodised oll : This method has the advantage of giving protection for 4 to 5 years after one injection.
Recent observations on the effects of iodinated oil show that a single injection corrects the iodine deficiency and restores normal thyroid function, The iodinated oil not only reduces the prevalence of endemic goitre, but also has the same effect on cretinism and suggest the possibility of an improvement in psychomotor development of children living in an endemic goitre area, The injection method has, however, some disadvantages since it is expensive anc it is difficult to reach everyone in the goiterous areas and persuade him/her to take the injection 91 Chapter-12 MANAGEMENT OF DIARRHOEA Diarrhoea in children is a major problem affecting their nutritional status.
Itis the result of poor environmental sanitation, lack of personal hygiene coupled with already existing state of under-nutrition.

A child with diarrhoea can easily be compared with a ‘leaky pot’ because all the inputs such as supplementary feading, heaith care etc, will be drained out if diarrhoea is nat controlled.
The implications of diarrhoea are, therefore, many such as retarded growth, poor nutritional status, extra load on health care services, pre-mature loss of young life etc, Various aspects of diarrhoea and its management are discussed in this chapter under the following sub-heads — What is diarrhoea ?

— Why is diarrhoea dangerous 7 — What causes diarrhoea ?

— Detecting children with dehydration, — Deciding which children need special treatment.

—- What is Oral Rehydration Therapy (ORT) ?


— How to give the solution to the child ?

— Feeding during and after diarrhoea, — How toinvolve parents and other members of the family in the treatment of a child with diarrhoea ?

— How to prevent diarrhoea ?

— Simple rules for treating diarrhoea at home.

What is diarrhoea?

Diarrhoea is a condition in which stools are passed more frequently and are looser or more watery than is usual for the person.
People vary in the type of stools they pass, and how often they pass them, but asa general guide, three or more loose or watery stools in a day can be considered as diarrhoea.

Frequent passing of normal stools is not diarrhoea.

Breast-fed babies often have stools that are very soft, but this too is not diarrhoea, 92 A mother usually knows when her child has diarrhoea, When diarrhoea occurs, mothers may say that their children's stools smell strongly and pass noisily, as well as being loose or watery.
By talking to mothers a usaful local definition of diarrhoea can often be found.

Diarrhoea is most common between 6 months and 3 years of age.

It is.

also common in babies less than 6 months old who are drinking cow's (or another animal's) milk or infant feeding formulae.

Diarrhoea is an iliness that requires immediate care.

It should never be neglected.

Why is diarrhoea dangerous ?

The two main dangers‘of diarrhoea are death and malnutrition.
Death from diarrhoea is usually caused by the loss of large amounts of water and salts from the body in the frequent watery stools.

This is called dehydra- tion.

Small children with severe diarrhoea lose water and salts rapidly and can die quickly, sometimes within a few hours.

Many children with diar- rhoea recover by themselves, but they become weak.

Mainutrition can be caused by diarrhoea because food passes too quickly through the bedy and therefore cannot be absorbed properly.
Moreover, a person with diarrhoea usually feels too ill to be hungry and so does not eat.

Adults suffering from diarrhoea are often afraid to eat because they think tnat gating will make their diarrhoea worse.

Diarrhoea is more severe and more common in people who are already suffering from mainutrition.

In many communities it is a common practice to starve children when they have diarrhoea.

Sometime, even breast-feeding is stopped.


This is wrong because it causes malnutrition, which will make the child have diarrhoea more frequently.

To prevent malnutrition in children with diar- rhoea, it is important to give them correct treatment and proper nutriton.

What causes diarrhoea ?

Diarrhoea is caused by .an infection of the bowel by very small germs or organisms that cannot be seen by the naked eye.
They enter the mouth and then the bowel through dirty hands, dirty food, dirty milk, dirty water, dirty feeding bottles, dirty cooking pots and feeding vessels, and so on.

Some of them are also passed out in the stools.

When other peapie come into contact with these germs, because of lack of cleanliness, the infection spreads.

What causes dehydration ?

The body takes in water and salts from drinks and foods.

When the bowel!
When the bowel!

is heaithy, the water and salts pass from the bowel into the blood and are then carried to all parts of the body to be used.

The water and salts that the body does not need are passed out through stools, urine and sweat.

Water and salts may also be lost by vomiting.

When there is diarrhoea, the intestines do not work normally and the water and salts pass into the blood very slowly or notatall.
As aresult, the body does not take up as much salt and water as it needs to replace what it is losing, and more than the normal amounts are passed in the stools.

Thus.

the body is drained of water, salts and nutrients; this is dehydration.

Diarrnoea may some- 93 times be accompanied by vomiting, which increases the rate of dehydration The worse the diarrhoea, the more water and salts a person loses and the more he is dehydrated.

A lot of vomiting and sweating can also cause dehydra- tion.
Dehydration occurs faster in hot climates and when there is fever.

Persons of any age can become dehydrated, but dehydration develops more quickly and is most dangerous in smail children, since small children, due to their greater surface area in relation ot weight and higher metabolic rate, require 24% times more fluids per kg.

of body weight than adults.

Dehydration as a result of diarrhoea and.vomiting is very common in India, particularly in rural and tribal areas and urban slums.
There is sudden loss of essential fluids and salts from the body of the person affected with this disease, If it is not timely checked, it may even lead to death.

Fig, 10 Detecting children with dehydration.

All children with diarrhoea are in danger.

Many children recover, but some become seriausly ill, How can the field worker identify the children who need urgent care ?

Four things they should do are - ask, look, feel and weigh.
The signs of mild or severe dehydration and ways of detecting them are summarised in Table 1, STEPS TO TAKE TO IDENTIFY CHILDREN WITH DEHYDRATION Table-1 What to do 1.

ASK Signs to loak for Signs to look for Danger signs DIARRHOEALess than4 4-10 liquid liquid stools — Stools per day.

liquid stools per day More than 10 VOMITING.

THIRST None, or small Some amount Normal URINE Normal 2.
LOOK AT CONDITION Well, alert per day or Much blood & mucus Very frequent है More than normal Small amount, No urine for dark yellow 6 hrs.

Unabie to drink ‘Unwell, sleepy Very sleepy, or irritable floppy, unconscious having fits or convulsions, Very dry and sunken, EYES MOUTH Normal Sunken AND TOUNGE BREATHING Normal Wet Dry Faster than normal Very dry.

Very fast and deep.

3.FEEL SKIN Apinch goes Apinchgoes Pinch fold goes back quickly backslowly backwvery slowly PULSE Normal FONTANELLE Norma!
{in infants) Fasterthan normal Very fast, weak or cannot be felt.

Sunken Very sunken.

4.

WEIGHT (if possible) 5:TAKE TEMPERA- TURE (if possible) 6, DECIDE No weight loss Weight loss of Weight loss of 25-100 grams more than 100 during for each kg.

of grams for each diarrhoea weight illness.

kg, of weight.

- न High fever: more than 38.59C (1019F) Ifthe child or adult with diarrhoeais like this there is no de- hydration.
If the child or adult with diarrhoea has Ifthe child or adult with diarrhoea has-2 or more 2 or more of of these signs.

these danger signs there is there is some.

severe de- dehydration hydration.

it is important to know if a child is only mildly ill or seriously ill because this affects the action you should take.

A child who has mild diarrhoea can be treated at home, but a child who has severe diarrhoea, dehydration and compli- cations should be sent to the nearest health centre for special treatment.
Deciding which children need special treatment Special treatment is required by children with diarrhoea if they : — Have severe dehydration — Have other diseases and complications of diarrhoea — Do not improve with the treatment described in the section below.

The field worker should be able to recognize such children; and should send them as soon as possible to a supervisor, health centre, or hospital.

— Dehydration is dangerous in diarrhoea.


— Dehydration is caused by loss of water and salts from the body.

— Save.a child with diarrhoea by rehydration.

What is Oral Rehydration Therapy (ORT) The easiest way to save the life of a child with diarrhoea and dehydration is to reptace the lost water and salts by giving him a solution of water and salts by mouth.

This is called Oral Rehydration Therapy or rehydration.
This therapy is very effective way of compensating for fluids and salts losses occuring in dehydration.

This can be done by adding clean water to a specially prepared mixture of salts available as a powder in sealed packets.

Salt and giucose are the two main ingredients of this mixture.

This: salt mixture is Known as 95 Oral Rehydration Saits (ORS).

Mix the contents of one standard packet of oral rehydration salts in one litre of clean drinking-water and stir to make a solution.
This is commonly known as ORAL REHYORATION SOLUTION.

When packets of oral rehydration salts are not available, a rehydration solu- tion can be made at home.

The field worker should be taught how to make such a solution.

As a general rule, 40 g of ordinary sugar and 4-5 g of common salt should be mixed in 1 litre of clean drinking water, Itis extremely importntto mix the sugar, salt and water in the correct proportions, Fig.
11 A simple salt and sugar solution can be made at home as follows : Clean boiled water (5 cups = 1 litre) - Salt (1 tsp.

level) i" Sugar (8 tsp.

level) itis usually preferable to make smaller quantities at a time.

Take a glass of clean drinking water, add a three fingers pinch of saltand a scoop of sugar (four fingers scoop).

If avgilable, add juice of half lemon into it.

This not only improves the taste but also provides potassium; an important electrolyte.
gy 4 1 pinch (three fingers) salt 1 1 scoop (four fingers) sugar Some of the points for consideration while making Oral Rehydration Solution 818 : — Taste it and make sure that it is not saltier than the taste of tears.

— Do not boil the mixture: — Do not keep the mixture for more than 24 hours.
— Make fresh mixture daily, — Preferably make smaller quantities at a time, How to give the solution to the child The prepared solution should be kept in a cool piace and kept covered to protect it from flies and dust.

Use the fluid on the day it is prepared.

Throw away any fluid that was prepared the day before.

Small amounts of the fluid should be given to the child every few minutes.

The best way is to give 2-3 small spoonfulls fron a cup, wait tor 2-3 minutes, then give some more.
In this way, the child is less likely to vomit.

If he does vomit, wait for 5-10 minutes, then give some more.

Vomiting is nota reason to stop giving the solution, unless it is severe and frequent.

\n that case, the child should be taken to the nearest health centre, 96 Fig 10 Dehydration in children a +e SS AE sa EMADE SUGAR AND SALT foun ether salt sugar waler Fig 17 Oral Rehydration Solution Points for consideration while administering the ORS are : — Do not give large quantities of ORS at a time.
— Give sips of the drink every 5-10 minutes or as frequently as possible, day and night until the person begins to pass urine normally and 100४5 rehydrated.

— Use a clean cup and spoon.

— If the child is fatigued or drowsy, he can be fed with a nasogastric tube (recommended rate 15 mi/kg/hr.

to 20 mi/kg/hr.

for more severe cases and when the child is in shock) at the health centre.

— Vomiting is not uncommon during the first one or two hours, Do not discontinue ORT because of vomiting.
Initially give slowly in small sips.

— If vomiting persists, intravenous fluid may have to be given.

— Forced feeding in large amounts toa very sick and drowsy child oraninfant who is vomiting can result in aspiration of ora} rehydration fluid or vomitus.

— Due to gastrocolic reflex, a child may pass stools on taking ORS.

Reassure the mother of the child or patient and continue ORS.

Inform the patient or the child's mother that ORS is to prevent dehydration and not to stop diarrhoea.
Feeding during and after diarrhoea.

Many people think that all foods should be avoided during diarrhoea, because foods will make the diarrhoea worse.

This is wrong, Foods are needed to replace what is lost during diarrhoea.

If a child with diarrhoea is on breast milk, the mother should continue to breast-feed him.

Several studies have shown that bottle-fed babies have more diarrhoeal episodes than breast-fed babies.

Breast milk is safe, clean and nourishing.


Breast milk should be given between drinks of oral rehydration solution.

NEVER STOP BREAST-FEEDING DURING DIARRHOEA.

Breast-feeding must be continued for the following various reasons : — Breast milk supplies the baby fluid, calories as well as nutrients and electrolytes like potassium.

— Discontinuation of breast feeding and fasting may lead to decrease in or cessation of breast milk and this may’ make the baby more prone to malnutrition and infections.
So-called “resting the bowel” leads to dim- inished capacity to absorb glucose, salt, water and amino acids, — The.child needs the milk to build up his immunological defence and fight against infection.

— Ahealthy child who is fasting loses on an estimate 1-2% of body weight daily.

In addition to this, if the child has diarrhoea, the loss is much more.

— Asick child needs the mother’s protective arms and closeness, Neither an |.V.
needle stuck in the baby's arm nor even spoontuls of ORS can provide this, but the mother who breast feeds her baby can.

— In a hospital study, it was observed that breast-fed children had a totai calorie intake 35% greater and a protein intake 2\% times greater than children who were completely weaned.

Breast milk is a low cost, highly nutritious uncontaminated food source.
— The reduction in calorie and protein consumption during sickness Is also minimised and there is no negative metabolic balance and weight loss.

99 — There is no evidence of milk intolerance in breast fed infants.

Ifthe child ison cows milk or artificial formulas, the feeds should be diluted to half-strength with clean water.

Such feeds should be given between drinks of oral rehydration solution.

Full strength milk should be started again when diarrhoea stops.
Ifthe child normally takes solid food, he should be given soft, easily digestible foods (porridge, etc.)

during diarrhoea.

Smail frequent meals should be given between drinks or oral rehydration solution.

Feeding a child who is ill requires extra patience, time and care.

After recovery from diarrhoea, extra food should be given.

Try to give a little more than the child normally eats.

Small feeds in between the main meals is also 4 Good approach.
How to involve parents and other members of the family in the treatment of a child with diarrhoea.

Expiain to the parents and other members of the family in simple words what diarrhoea is and how it can be treated.

Teil them how you are examining the chiid and what are the signs of dehydration, Show them how to prepare the rehydration fluid and ask for their help in its preparation.
Once the solution is ready, taste it yourself and ask the parents to taste it also, They should notice that it is not as salty as tears.

Some mothers may fear that giving fluids may make the diarrnoea worse.

Reassure them and expiain that the water lost from the body should be replaced.

If this is not done the child's life may be in danger.

.

Encourage the mother to use a cup and a spoon to feed the solution to her child.
Teach the parents everything they need to do to care for a child with diarrhoea, a flip-chart may be useful for this.

Provide the mother with packets of Oral Rehydration Salts.

If the diarrhoea is severe and the home is far away, give the mother more than one packet.

She should use these until her child is completely well or until he is seen by you again.

Advise the mother to bring the child back if his condition gets worse, if vomiting becomes severe, or if he cannot drink.
If possible, the mother should always bring the child back the next day.

This is to make sure that the child is getting better and to repeat the teaching about rehydration, feeding and prevention of diarrhoea, Explain to the parents the importance of feeding during diarrhoea.

Only when they see that giving properly selected foods does not worsen diarrhoea, they will be convinced How to prevent diarrhoea Breast-feeding protects against diarrhoea and other infections.

jt also provides excellent nutrition.


Do not bottle-feed.

Bottles are difficult to clean and germs grow easily in the artificial milk formulae.

Diarrhoea is common in bottle-fed children.

BREAST-FEEDING !S THE BEST WAY TO PREVENT DIARRHOEA IN INFANTS.

Diarrhoea germs come from stools.

If stools are passed where people cannot 100 came into contact with them, the germs will not spread to others.

Latrines should be built, used, and kept clean.

Dirty water can cause diarrhoea.


Water for drinking must be clean and should be kept in a specia!

pot.

Never put hands in drinking-water.

Drinking-water for small children should be boiled.

Flies can carry the germs of diarrhoea.

Flies settle on stools, pick up germs and then settle on food, Cover food to protect it fram flies.

If children pass stools near the house, the stools should be removed and covered with earth.

Simple rules for treating diarrhoea at home 1.


As soon as diarrhoea starts, give your child more fluids than usual, for example : rice water, fruit juice, coconut water, weak tea, soup orsaltand sugar soijution and breast milk, or milk feeds which you mix with equal amounts of water.

2.
2.

Give the child food - as much as he wants, 5-7 times.a day, whichis easy to digest, for example, boiled rice, porridge, soup, egg, fish and well- cooked meat, food which contains potassium, for example, banana, carrot, lentil and pineapple: 3.

Look and feel for the signs of dehydration.

Here are some of them : Greater thirst, dark urine, unwell, sleepy or irritable condition, sunken eyes, sunken soft spot on the top of the head, a pinch of skin goes back slowly.
Take your child to the Health Centre or field worker if you see any of these signs.

4.

You can prevent diarrhoea, if: You give your child fresh, clean.and well-cooked food.and clean drink- ing water and practice good hygiene.

Some key points to remember in diarrhoea : 5 Rules to prevent diarrhoea are : — A well fed child is strong and does not get diarrhoea; so feed your child well, — Provide sanitary latrines for use by the entire family: wash hands thoroughly after using toilets.
— Feed the child only after washing hands.

— Give freshly cooked food to the child as far as possible, If not, heat the food before feeding the child to minimise the chances of infection, if any.

— Keep drinking water and food in clean and covered containers to keep off flies and dirt.

— Use safe drinking water only.


5 Rules for better care during diarrhoea are * — Give enough fluids to drink to make up water loss — Makelifesaving ORS at home using standard formula if packed ORS is not avairable- — Give ORS after every watery stool and in small sips over a period of time even if there is vomiting.

— Feed the child with easily digestible food since food withdrawal may render the child weak, and it can not fight diarrhoea.
— If diarrhoea and vomiting are severe and continuous give ORS drink and take the child to the nearest health centre.

101 Chapter-13 IMMUNIZATION The inter-relationship between nutrition and infection has been well estab- lished.

The prevalence of infectious disease directly affects the nutritional status of acommunity while the level of nutrition ina community determines the incidence of morbidity and mortality due to infections.
The control and preven- tion of infectious diseases through immunization is, therefore, an essential part of a nutrition policy.

Various aspects of immunization are discussed under the following subheads — What is immunization ?
— Immunization — an indirect Nutrition Programme -- Diseases preventable by Immunization — Immunization Schedule — Development of an information system and feedback What is Immunization - The two main ways of preventing infectious diseases, as discussed in the (t) by chapter of Personal Hygiene and Environmental Sanitation also.
are: decreasing the chances of individuals coming into contact with the germs, and (ii) by strengthening the defence system of individuals so that even if they are infected, the germs cannot cause disease.
Tne first method is really improving the environment or the area in which people live For example, if everyone uses latrines, has plenty of water to wash, 102 | throws rubbish away in.a protected pil, the environment willbe clean and there will be little chance of getting germs from someone with the diarrhoea or other infectious disease.

The defences of an individual against infections can be improved In a general way or in specific ways.
A better state of nutrition means that an individual's defences can function fully against any infections.

In other words, good nutri- tion means good defence against infections, This is a general improvement.

An improvement of the defences against specific infections can be achieved by immunization.

Immunization can be “natural immunization" or “artificial immunization”.
If a child suffers from measles and recovers, he is not likely to get measies again, This is because during the illness, his body has made anti-bodies that kill measles germs.

This remains in his body and if in later life, he is attacked by measles germs, the antibodies will kill those germs.

Thus the child who has had measles becomes protected against the disease by the antibodies that his body makes.

The child thus protected is said to be “immune to" or “have acquired natural immunity against” measles.
This is called “natural immunization”.

Unfortunately, in the case of cough and cold or diarrhoea, for example, one attack Goes not give a life-time protection.

Itis also possible to produce “artifical immunization”.

This is done by inject- ing “weakenec" germs into the body, These germs attack the body but are not strong enough to produce the signs of the disease.
However, they do cause the body to produce the antibodies that kill the disease germs and thus protect the body from future attacks of the disease.

A substance which can produce specific artificial immunization is called a "vaccine".

There are a number of valuable vaccines which can immunize and pretect against serious infections.

Breast milk also contains protective substances against the germs that cause various infections, Thus breast milk also increases the body's defence against infections.
immunization — An Indirect Nutrition Programme : ltisa well recognised fact now that the occurrence of infectious diseases such as measies in children is a common cause of malnutrition and that mainour- ished children get more infections which are more severe and last longer.

All infectious diseases are nutritionally harmful.

Measles for example, is an infec- tious disease that attacks children mainly when they are between 9 months and 5years of age.
In some countries, itis an important cause of death among young children.

Measles germs travel through the air from one child who has the disease to another child whais not protected against measles.

The children with measies become very ill with fever, rash, sore-throat, bad cough, fast and difficult breathing, diarrhoea, and sometimes unconscious, This makes the child lose his appetite and he also refuses food because his mouth is sore.
During fever, the child uses more energy than normal, but because little food is being taken in, the body has to use up its own tissues (food stores) for eneray.

In certain communities people believe that itis harmful and wrong to feed a child who has measies and so children are starved tor days and even weeks.

The children with measles, therefore, lose a lot of weightand become malnourished This can be clearly seen on the growth charts of children who have had measles.
Many children die because of the combined effects of measles and malnutrition.
The following figure illustrates how infection increases malnutrition at the same time as the mainutrition makes the infection worse, 103 INFECTION poor appetite uses up body stores पु cannot absorb food wetl food taboos s e ~ MALNUTRITION weakens body's defences therefore infections are worse and last longer Figure 1 — The circle of infection and malnutrition To break this circle of illness, it is necessary to treat both conditions i.e.
infections as well as malnutrition because treating only one of them gives pour results.

In other words, the control and prevention of infections through immun- ization is as essential as fighting the problem of malnutrition, for improving the nutritional status of the people.

The immunization programme is, therefore, an indirect nutrition programme for improving the nutrition of the people.

Community benefits from immunization programmes in two ways.
First, immunization prevents both infection and malnutrition, Secondly, the pro- gramme gives an opportunity to the community to participate collectively in its own health care programmes.

Efforts should, therefore, be made to propagate the following messages in the community : i) Start the vaccinations early in the first year ii) Try and compiete the series of injections, iii) Make sure that the mainourished children are vaccinated, they are a priority group.
Diseases preventable by immunization : There are a number.

of vaccines that can give immunity against diseases These are very valuable in protecting children against dangerous diseases of childhood.

The vaccines are made.and given in different ways.and have to be given at about the right age for the best effect.

Immunization also needs to be repeated at certain intervals.

There are six important and common diseases for which there are vaccines.
These diseases are : measles, tuberculosis, whooping cough, diphtheria, teta- nus, and poliomyeiitis.

The diseases preventable by immunization usually strike the children early during infancy or the pre-school period.

For example, major- ity of the children get infected with polio viruses before two years of age, poliomyelitis being quite rare in children above 5 years in India, Complications following whooping cough are known to be more severe in infants and young children.
Diphtheria, tetanus, tuberculosis and typhoid fever are also reported 104 in-school-going children.

it is important that all the cases of the vaccine preventable diseases are recognised in time and reported to the local health authorities so that treatment could be started in time and preventive measures taken to check the further spread of the diseases.
A brief account of vaccine preventable diseases is therefore given below : Neonatal tetanus : Tetanus is one of the major causes of neonatal mortality in the country.
The problem of tetanus is compounded by the fact that not only the germ of tetanus (Clostridium tetani) is widespread, butalse that tetanus spores are highly resistant and can survive for long period in the soil, The risk of exposure of the new born to the spores, specially in the rural areas is extremely high since the Surrounding environment is heavily contaminated with these spores.
The symp- toms of the disease appear 3 to 14 days after birth and death rapidly follows often before the child can be taken to a health centre for treatment.

Even in the hospitals, the case fatality rate continues to be high with the death of ne irly three out of every 4 cases admitted.

Convulsions in the second or third week of lite may be due to meningitis or tetanus.

Bulging anterior fontanelle with fever should lead one to suspect meningitis.
Fits in Neonatal Tetanus (NNT) are worsoned by noise or move- ments.

Due to tightening of muscles around the mouth in NNT the child is unable to suck.

The disease is, however, preventable.

The control measures are directed lowards taking adequate precautions to avoid infection at the time of cutting the cord or by placing unclean dressings On the umbilical stump.

The immunization of women during pregnancy provides protection to the infant for the first few months of life.
Two doses of tetanus toxoid are required to be given, the second at least two weeks before birth Coverage of the women with tetanus toxoid can lead tea virtual elimination of the disease in the new borns.

The vaccination, however, provides individual protection and the services must be continued even in the absence of clinical disease in the area.

All efforts must be made to propagate the following methods of prevention of this disease : i) Immunization of pregnant women — give two doses of T.T.
Interval between doses should not be less than one month, ii) Hygienic care at birth — use a sterile blade for cutting cord, iii) Post natal care — do not put unclean dressings on the umbilical stump.

Tetanus in others : Tetanus can also occur in older children and adults.

The spores enter the body when broken skin (cuts, wounds, bums) is contaminated with soil, dust or other substances containing tetanus.

spores.
spores.

Unsterilisednstruments used for @xtracting teeth, or cleaning ears can also transmit the spores, The patient complains of painful spasms and twitching of the jaw muscles.

The body is characteristicaily bent like a bow due to the contractions of the muscles of the neck and the trunk.

The case fatality rate is high.

The children should, therétore, be given all primary and booster doses of tetanus vaccine.
Incase the child or an adult has not been vaccinated earlier, he must be given tetanus toxoid whenever there is an injury 105 Diphtheria : When a child comes with fever and also complains of asore throat, the throat should be checked to see if there is a membrane.

Within four to six days after the symptoms appear, the child can be very ill with a markedly swollen throat and a greyish membrane with well defined-edges in the throat if the child has diphthe- ria.

The child has difficulty in breathing.


The toxins liberated by the bacteria can also affect the heart muscles and the nerves.

Diphtheria is caused by Corynebacterium diphtheria.

The disease affects tonsils, pharynx, larynx, nose and skin.

The source of infection are patients as well as healthy carriers.

The bacteria are excreted from the last day of the incubation period throughout the course of the disease.

The bacteria spread from one person to another in small droplets through the air.
They can also spread by direct contact or indirectly through objects, such as toys, clothes, crockery etc., freshly contaminated with the throat and nose secretions of the patient.

All children between 0 to 5 years should be protected against diphtheria by giving them three doses of DPT vaccine.

These children should also:be given two booster doses between 1% to 2 years and 5 to 6 years of age: Whooping cough : The symptoms appear 5 to 8 days after contact with a patient.
The disease develops slowly with slight fever, cold and irritating cough which gradually becomes paroxysmal, usually within one to two weeks, and lasts for one to two months, Paroxysms are characterised by repeated violent cough.

During coughing fits there is difficulty in the inhalation of breath.

The coughing fits are followed by a high-pitched inspiratory whoop and frequently there is an expul- sion of clear thick mucus.
The eyes may bulge during coughing spasms and there may be bleeding in the eyes or eyelids.

The child vomits after severe bouts of coughing, Young infants may not have typical paroxysms.

Whacping cough can lead to malnutrition and secondary infections specially pneumonia.

Whooping cough is caused by ‘Bordetella pertussis’.

The source of infection isa sick child.


The child is very infectious during the early stages of the disease before the typical symptoms of cough have appeared The bacilli spread in small droplets through the air.

They can also spread by indirect contact with articles freshly soiled with respiratory discharge of infected persons.

All infants should be protected against whooping cough by giving them 3 doses of DPT vaccine between 3 to 9 months of age and a booster dose between 18 to 24 months of age.
Poliomyelitis : Young children with fever should be examined for pain or weakness of the it is muscles in the legs or arms.

Paralysis of one or more limbs may follow if poliomyelitis.

The paralysis does not progress further once the acute phase of the disease is over.

Paralysis is of the flaccid type; pain and tactHe sensajions of the affected limb are normal.

Symptoms usually appear 5 to 14 days after infection.
The severity of the disease ranges from inapparent infection to non-paralytic and paralytic disease.

The patient complains of fever, headache, gastrointestinal distur- 106 | weakness and stiffness of the neck and back.

There may also be paralysis.

Paralysis is characteristically asymmetrical and usually of the lower extremities.
Paralysis of the muscles of respiration and swallowing may lead to death and paralysis of the limbs can disable the child for life Poliomyelitis is caused by polio viruses types |, I!

and Ill.

The source of infection are patients and more frequently children with inapparent form of infection.

The cases are most infectious 7 to 10 days before and after the onset of symptoms.

The viruses are excreted with faces and spread through contaminated food, water and articles of daily use.
The viruses can also spread through the air in the form of small droplets Poliomyelitis is a serious disease which can paralyse and cripple the person but it can be prevented by oral poliomyelitis vaccine.

The vaccine is usually given to infants between the ages of 3 to 6 months.

The immunization can, however, be started from 6 weeks of age — 3 doses at 4 weeks intervals.
For full protectionn the child needs to nave 3 doses at 4 to 6 weeks intervals, To maintain the protection a booster dose is necessary between 18 to 24 months.

The vaccine is given in the form of drops placed in the mouth.

Breast feeding must be avoided for 4 to 6 hours before and after an infantis given the vaccine, However, the baby can be given other food and fluids provided it is not served hot.

Tuberculosis : Tuberculosis should be suspected in case of low grade fever for a number of days.
The child is listless and there may be loss of weight.

Tuberculosis can affect any part of the body.

In tuberculous maningitis there may be high fever, severe headache, stiffness of the neck and convulsions.

Tuberculosis of the glands may lead to suppuration and open wounds, The most common form af tuberculosis is that which affects the lungs and which is transmitted through indiscriminate coughing and spitting of affected sputum, The disease is caused by ‘Mycobacterium tuberculosis’.
The most common source of infection are tuberculous patients.

Untreated or inadequately treated patients may periodically discharge the bacilli in their sputum for years.

Tuber- culosis of organs other than the lungs without a discharge is not directly communicable.

Antimicrobial therapy generafly reduces communicability within a few weeks.

The disease can be controlled by immunization of young children with BCG vaccine.
Children must be given BCG vaccination within the first year of life in order to protect them against tuberculosis.

BCG vaccination is simple, and safe procedure which consists of injecting a small amount of vaccine just under the skin.
If a scar does not form at the BCG vaccination site within 3 months, the parent should report this because this means that the child is not protected against tuberculosis Measles : Fever with catarrh and watering of the eyes fcllowed by rash on the third or fourth day starting from the face and spreading downwards may be due to measies.

The symptoms appear about 9 to 10 days after close contact with a patient.
There is fever, conjuctivitis, running nose, bronchitis and small white spots (Koplik’s spots) on the inner surface of the cheeks.

A characteristic dusky red 107 blotchy rash appears on the third or fourth day.

The rash first appears on the face and gradually spreads over the whole body.

The rash lasts for four to six days.

An attack of measles may lead to secondary infections of the lungs, ears, eyes and gastrointestinal tract.

The complications can be severe, specially in malnourished children.
Measles is caused by measles virus.

The source of infection are patients who may excrete the virus a few days before and for about 2 weeks after the appearance of rash.

The virus spreads through the air in small droplets.

There is no transmission via articles or clothing or through an intermediary due to the low stability of the virus Children can be protected against measies by immunizing them between 9 to 12 months of age.

The vaccine can, however, be given upto 15 months of age.
Typhoid : Typhoid fever may give rise to prolonged fever.

Approximately two weeks after infection, the patient compiains of continuous fever, headache, weakness, loss of appetite, irritability, sleeplessness and constipation.

The lips are cracked and the tongue is coated a dirty brown.

The liver and spleen are enlarged.

Typhoid fever is caused by ‘salmonella typhi’ and paratyphoid fever by 'S.

paratyphi A’.

Paratyphoid fever B is rare in India.


The bacteria spread through food and water contaminated with the faeces or urine of patients and healthy Carriers.

Children aged 5 to 16 years should be vaccinated against typhoid regularly (as recommended in the Immunization Schedule) particularly in those areas where typhoid is found to occur.

Cholera : Cholera is a serious disease transmitted through contaminated water, milk or food and water contaminated with the faces urine of patients and healthy hours.
Cholera vaccine is not given asa routine but it is given to the entire commun- ity when there is a danger of an out-break of the disease.

Immunization Schedule : As already painted out, the major causes of sickness and death of childrenin India are infectious diseases many of which are preventable by immunization.

Since safe and effective vaccines are available for the control of the above mentioned diseases, this should not be allowed to happen.
The Governmentof India started the Expanded Programme on Immunization (EPI) in 1978 with the objective of reducing the morbidity and mortality due to diphtheria, pertussis, tetanus, poliomyelitis, tuberculosis and typhoid fever by making vaccination services available to all eligible children and pregnant women by 1990.

Other diseases will be included when and where necessary.

It wasalso aimed to the achieve self-sufficiency in programme.
the production of vaccines required for Each country frames its own immunization schedule keeping in view the epidemiological pattern of the diseases, the types of vaccines available and the administrative and economic feasibility of providing the services.

The following schedule has been recommended in the country : 108 IDEAL IMMUNIZATION SCHEDULE |.

FOR PREGNANT WOMEN As early as possible during pregnancy After one month of Tetanus-1 One injection One injection Tetanus-1t Tetanus-2 (Booster) It.
FOR CHILDREN 1% month} | One | 2% month | manth}| 3% a 16-24 month!

months] yrs.

[5 10 and 16 ५5. ie Inj, 2nd Inj.

3rd Inj.

| 1st 2nd Dose | Dosa | Dose 3rd Booster Inj, Booster Dose | One| lone | | One | B,C.G.

* D.PLT we Measies D.T TT *Ifchildts born in a hospital or aclinic, BCG vaccination should be given at the time of birth NOTE — Interval between doses should not be less than one month, — Minor coughs.

colds and mild fever are not a contra-indication for vaccination.
— The recommended course of each vaccine must be completed as early as possible.

!f for some reason, the child did not get the scheduled dose in time (within 4 to 8 weeks) he may be given the dase as soon.as possible without Starting the course agin — DPT and Polio vaccines are given to the onild at the same time.
BCG vaccine can be given with any one of the three doses but the sites of the injections of the DPT and BCG vaccines should be different Contraindications and reactions : Malnutrition, low-grade fever mild respiratory infections’or diarrhoea and other minor illnesses are not a contra-indication to vaccination.
Diarrhoea should not be considered a contraindication to Oral Polio Vaccine (OPV) butto ensurg full protection, doses given to children with diarrhoea should not be counted as part of the senes and the child should be aiven another dose at the first available opportunity immunization of children so ul!
as to require hospitalization, and those with high grade fever or otherwese acutely iil may pe deferred till a decision is faken by a medical oftiver 109 a A second or third DPT injection should not be given to a child who hada severe adverse reaction to the previous dose.

Instead a single dose of DT vaccine may be given.

Reactions after vaccination are in general mild and of a short duration.

These may be: — Mild fever.

— Local pain and swelling at the site of injection.

— Malaise, fretfulness.


— Transient rash (after measles vaccine), — A lump or papule appears in the third or fourth week after BCG vaccination.

It is generally not painful but is tender to touch.

The papule increases in size to 6 to 10 mm in diameter by the sixth week.

The nodule softens with the formation of pus.

No treatment is necessary.

At the end of 10 to 12 weeks only a small scar is visible.
Development of an information system and feedback; The immunization programme requires a close coordination of work between personnel engaged in various tasks at different levels.

The tasks must not only be done correctly but also in time in relation to each ather.

Itis, therefore, very important that people are not oniv aware of their job responsibilities but are well trained and motivated also.

A field level worker has great responsibility in an immunization pro- gramme.
Its success depends very.much on her.

She is the person who has to persuade the people that immunizations are worthwhile, Whenever she finds that the growth line on the growth chart of achild has come down after an infection, she should try to convince the mother regarding the.

advan- tages of immunization.


One of her important tasks is to explain the importance of the programme to the community and convince the community leaders in particular, With their help, she must identify all the children of the right age for vaccination and convince their parents of the need to have the children vaccinated.
The willing participation of the parents and leaders is important because the worker will need their help to get the children to the vaccination centre at the right time on the right day, and to bring them back again for their second and third vaccination at the correct intervals, A successful immunization programme is characterised by two principles: (i) Provision of the services at a convenient location near the residence of the recipients at a convenient time: (il) Active promotion of the service being offered.
Remarkable results have been obtained in various countries when these two principles have been kept in mind while organising intensive immun- ization’on particular days.

Educational and promotional methods have to be imaginative in order to achieve best results.

The use of all available mass media such as radio, TV, printed leaflets etc.

should be made to propagate the vaccination days, venue, time etc.
and also the impor- tance of vaccination, Immunization coverage can be significantly increased Ina very short time and at very little extra cost by developing a proper information system and feedback and the role of the field level functionary in this cannot be over emphasized.
140 Chapter 14 PERSONAL HYGIENE AND ENVIRONMENTAL SANITATION Personal hygiene and environmental sanitation play an important role in determining the nytritional level of the community by warding off many 111 + - ी र ् क common infections.

It is, therefore, important that ihe community is edu- cated about the necessity of developing clean personal habits and how to keep their surroundings clean.
The different aspects of personal hygiene and evironmental sanitation are discussed under the following sub-heads — Importance of Personal Hygiene and Environmental Sanitation, — Developing Ciean Personal Habits.

— Hygienic disposal of waste water.

— Disposal of anima!

manure and solid household waste.

— Hygienic disposal of human excreta.

— Home Sanitation.

— Smokeless chulhas.

— Safe drinking water.

— Food Hygiene.

— Control of insects, rodents and stray dogs.


Importance of personal hygiene and environmental sanitation: Ithas recently been recognised that matnutrition is not only due to dietary deficiency caused by insufficiency of food or poverty, but is a multifaceted problem created by the inter-twining of a large number of factors.
Some of the factors which directly affect the nutritional status of the people are food availability, purchasing power of the people, literacy level, prevalence of conditioning infections, available health services and population size.

Itis, therefore, evident that nutrition alone is not enough to maintain optimal nealth and that protection from infectious diseases is equally important.
If these two factors namely adequate food and protection from infectious diseases are not taken care of simultaneously, the human body will remain only a “leaky-pot’.

In other words, all the nutritious food consumed by the person will be leaked out through the infectious diseases like diarrhoea respiratory infections ete Protection from infectious diseases can be achieved in two ways —firsily, through immunization, and secondly by maintaining good hygiene and environmental sanitation.
By doing so, we can ward off many common infections to which we are constantly exposed “Hygiene” The word is derived from the Greek word “Hygeia", the Goddess of health, who was supposed fo look after the health of the people Hygiene can, therefore, be defined as the science and art of preserving and improving health, It is sclence because it is based upon scientific knowl- edge, and an art because it involves the development of skill in the systematic application of the knowledge to the daily routine of life.
It includes all such agencies which have a bearing on physical and mental health of man.

Hygiene deals both with the individual proper and the community 85 8 whole.

The branch of hygiene that concerns itself with the adjustments which the individual must make to presérve and improve the health of his body and mind is known as personal hygiene.

The art and science of maintaining, protecting and improving the health of people through organised communicable effort is known as public healtn.
It is concerned with the control of communicable diseases in the protection of the commun - ity and with furnishing medical services to special groups of persons.

112 Sanitation is the branch of public health which is concerned with keeping the external environment healthful.

The word ‘Sanitation’ is derived from the Latin word “Sanitas" which means a state of health.
Environmental sanitation means the control of ail those things in man’s surroundings which cause or may cause a bad effect on his body's development, his health and his length of life.
In other words, environmental sanitation is the cleanliness of house and surroundings of man, A Sanitarian directs his efforts towards the maintenance of safe drinking water free from pollution and harmful organisms, controls the disposal of sewage, conducts inspec- tion of sanitary conditions of food supply, enforces housing regulations and supervises the control of rats.

flies, mosquitoes and other intermediate sources of disease transmission.
Social hygiene deals with the problems of sex trom the health point of to the measures adopted for the control of venereal refers view and diseases.

Industrial hygiene is the study and application of the principles and practice of hygiene and modern medicine to the special problems of health and disease, as they are met with in the industry The World Heaith Organisation defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
Itis the quality of life that enables the individual to live most and serve best.

Optimum heaitn is tne nighest level of health attainable by the individual.

Health is what everyone wishes to preserve and promote and so the food that we eat should help us to achieve this and not spoil it.

Food hygiene is, therefore, a science.

of extreme importance and wide scope.


importance of good hygienic practices in the manufacture, distribu- tion and preservation of food from the health point of view cannot be over-emphasised, Developing clean personal habits: Once we know what hygiene is, and why it is necessary, it is important to know how it can be maintained.
Teaching hygiene involves educating the citizens of today and tommorrow on the basic facts of survival and installing in them a desire to be hygienic in their selfand surroundings.

Sanitation isa way of life.

It is the quality of living that is expressed in the clean home, the clean farm, the clean business and industry, the clean neighbourhood, the clean community.
Being a way of life, it must come from within the people, Personal hygiene deals with matters which are the personal responsibility of every person.

Personal hygiene ‘s not only concerned with matters pertaining to health of a person but also includes certain personal factors conductive to good health.

They are habits, cleanliness of body, clothing, exercise, posture, constitution, environment ete.

Habits: Habits play an important part in the preservation of health.
They must be developed and practised in daily living.

They are more difficult to change: than they are to form.

So, good habits should be installed from an early age Habits are largely responsible for determining one's quality of lite.

Some of the important areas are Eating and drinking habits: |t is essential to form a regular habit regarding zating and drinking 113 to can lead Only wholesome food should be taken for the preservation of heaith.
Meais should be taken after due intervals, at fixed hours and quantities compatible with one’s work.

Eating when fatigued should be avoided.

Poor eating constipation and obesity or indigestion, habit underweight.

Alcokol: tt is a food and a narcotic, but its food value is very limited, In small doses it aids digestion or induces sleep, but it has devitalising action upon the tissues, the symptoms of which range from some impairment of function to gross degenerative lesions.
Use of alcohol and other liquors should, therefore, be avoided, The real danger of its use is its habit formation nature and for persons having weak self control, it very quickly ceases to be their servant but becomes their master.

Tea and coffee: Tea and coffee are not so dangerous and are less habit forming than alcohol.
In addition to being pleasant beverages they are usetul as stimutants, but excessive use of sither is dangerous as it leads to great mental stimulation and loss of sleep, Besides, tannin present in tea affects the bio-availability of iron present in food.

Excessive use of tea and coffee affects the digestion and erodes the lining of the stomach thus causing Dyspepsia, Hyperacidity etc, Smoking: Smoking is injurious to heaith.

Smoking where there is food is an offence against law.
Heavy smokers are likely to suffer from Bronchitis, Tuberculosis, Cancer of the lungs etc.

Spiting: Spitting indiscriminately and coughing or sneezing without cover- ing the nose and mouth are not only dirty habits but are dangerous because they can cause the spread of various respiratory infections includingT uber- culosis.

Spitting should, therefore, never be done and proper precaution must be taken before coughing or sneezing in public.
Posture: By posture is meant the characteristic form in which the body is maintained during its various activities.

Goodness of posture consists in alignment of parts in relaxation rather than tension and readiness for action, The vital body functions like respiration, circulation, excretion, digestion and coordination of body activities can be carried on unimpeded, when the body is in perfect physiologic balance.
Exercise: Exercise is very essential forthe normal growth and deveiopment of the body and perfect maintenance of health.

Without exercise muscles become weak and flabby.

It improves all the vital activities of the body like respiration, circulation, perspiration, excretion, digestion and metabolism.

The mind is refreshed and the powers of observation, precision and toler- ance are developed.

Exercise should be done in the early hours of the morning or in the evening.
It should not be taken within two hours of aheavy meal.

Games should be encouraged since they combine recreation with exercise.

The right type of exercise should be selected according to the age and physical condition of a person, The body which is exposed during exercise requires to be covered and protected from undue loss of heat.

Fatigue: The feeling of weariness is Known as fatigue.

Fatigue reduces both the quantity as well as quality of work which one can normally do.
Worry infrequently is a fore-runner of fatigue.

Over fatigue results when we use up physical and nervous energy faster than it is restored, The normal human cycle is activity, fatigue and rest.

This cycle is universal pheno- menon in life.

The accumulated wastes and piosons of fatigue are carried off by the blood during rest and sleep.

Proper rest and sleep are, therefore, necessary to avoid fatigue.

The art of relaxation can also hetp to overcome fatigue.

114 Sleep: Sleep signifies rest of the brain.


In fact it is time for the repair and refreshment of the whole body and mind.

The amount of sieep required varies with age.

For those who are engaged in mental work, sound sleep is rather more necessary than those engaged in physical work.
The bedroom should be well ventilated and drugs should never be used to induce sleep except in illness and that also with discretion Sleeplessness: |t is a very frequent condition and one incompatible with physical and mental health.
There are many factors which may cause sleeplessness, Emotional excitement at bed time, improper and‘ insuffi- cient food, insufficient amount of exercise, studying late at night, inability to bar from mind the events of the day, constipation or worrying over real or prospective troubles may keep one awake.

Insomnia is more prevalent among brain workers than among those who do physical work.
Having regular bed time, drinking a glass of hot milk just before going to sleep, assuming calm, mental and emotional attitude on retiring, taking physical exercise at bed time too can help to overcome Insomnia.

An individual troubled with insomnia should not subject himself to worry about it.

Free- dom from anxiety removes to a large measure the harmful results of loss of sleep and produces an attitude of indifference which tends to induce sleep.
Cleanliness of body: It is very essential for normal growth of each body.

In order to remain healthy, one must develop ciean personal habits concerning the cleanliness of ones body.

Some of the points for consideration are: Bath: It is very necessary not only for cleanliness but also for its beneficial action on the skin and internal organs.

A dirty skin is likely to get infected with pimples, boils, sores, scabies, or ring worm.
Regular bathing at least once a day using soap and water is, therefore, essential.

During summers it is desirable to have a bath in the morning and in the evening.

Bath should not be taken immediately after meals or after exhaustion due to fatique.

Hands: Hands should be washed with soap and water after defaecation, before preparing or serving food and before meals.

Hands must be tho- roughly washed frequently, particularly, after using the toilet.
Scrupulous cleaning of hands with soap and water is essential to prevent spread of infectious diseases, After washing hands, they must be dried with the clean towel or cloth, ‘inger Nails: Finger nails should always be kept short and clean as dirt can easily lodge under the nail and may carry infection.
Nails can be cleaned using an old tooth-brush with soap and water, Keeping the nails short and clean, will prevent worm infestation and diarrhoea Hair: Fair should be washed at least once a week or more often during the hot weather in order to keep it clean and free from lice.

Hair should be combed at least once or twice daily.

Combing is a good massage for the roots of the hair and helps in making hair strong and healthy.

Hair which are not cared for are likely to develop dandruff and may fall easily.
Mother should inspect their children's hair every-day preferably with a fine toothed comb, so that any l.ce or nits can be detected early and removed.

Lice, if present, can be removed in the following way — cut the hair short, if possible.

Wash the hair with soap and hot water.

Apply kerosene full strenght or vinegar full strength or benzy!

benzoate emulsion to the scalp.

Cover the whole head with a cap orscraf overnight.


Next morning comb the 115 hair with a fine toothed comb and remove lice and nits.

Wash the hair with soap and hot water.

Repeat treatment until no lice or nits remain.

The hair should never be scratched, combed or touched in the kitchen as germs Can transfer by the hands to the jood.

Mouth: There are many germs‘in the area of the mouth.
The mouth or lips should therefore not be touched by the hands particularly while working in the kitchen, The tongue should be cleaned every morning by tonque- cleaner, the mouth should be cleaned by gargling in the morning and at night atter taking the last meal or drink Teeth: Healthy teeth are essential for good health.
They must therefore be looked after to avoid decay, This can be done by daily brushing the teeth to remove the food articles, rinsing the mouth after each meal and reporting to the health worker if a person has a toothache.

The teeth should preferably be cleaned at least twice a day i.e.

in the morning and at night before going to bed.

Gums should also be looked after properly so that they are strong and can hold the teeth firmly.
After brushing, a massage of the gums by a finger helps to improve the blood circulation and make gums healthy.

The intake of some seasonal fruit or salad in the daily diet will provide enough Vitamin 'C’ for the health of the gums.

Ears: It is dangerous to poke sticks or hair-pins into the ears to remove wax as this can cause injury or infection of the ear.

This habit should be avoided.

Ear holes should not be touched with the hand while in kitchen as it can transfer the germs to the food.
Eyes: Any inflammation or injury to the eye should receive immediate attention.

The infection is presentin the discharge of the infected eye and is transmitted to the healthy persons through handkerchiefs ortowels soiled with discharge by direct contact with the eye of an Infected person, Eye infections are also spread through flies.
The following precautions should be taken to prevent eye infections : Avoid the use of common towels or handkerchiefs for wiping the eyes, avoid the use of common sticks for applying surma or kajal to the eyes, not exposing the eyes to dust and smoke and not allowing flies to settle on the face and eyes.

The use of surma or kajal should be avoided as it does not benefit the eyes in any way and may even cause harm due to the lead present in the surma.
The eyes should just be cleaned properly with soap and water during bathing.

Nose: The nose is an area where there are vast numbers of harmful bacteria.

The nose should therefore not be touched when food is being handled.

Itis also important that food places or working surfaces are not sneezed over as it spreads germs, The nose should thoroughly be cleaned everyday while having bath.
Feet: As we are standing for many hours during a day, care of the feet is important, They should be washed regularly and the toes kept short and cleaned.

The tired feet can cause general tiredness.

Since the feet contain many sweatglands, excessive sweating necessitates frequent washing of the teet and change of socks.
During hot weathers it is desirable to use sandals instead of closed shoes, External genitals: Sexual organs require cleansing even more than most of the other parts of the body, since a slight carelessness in this respect can give rise to various types of infections.

116 Cuts, Burns, Sores etc.

: It isimportant te keep all cuts, burns, scratches etc.

covered with a good water-proof dressing to prevent the harmful bacteria from infecting the other areas and food.
In fact, people suffering from such cuts should not be allowed to handle food.

Cosmetic: Cosmetics should be used in moderation.

They should not be put on in the kitchen and the hands should be washed well afterwards.

Cosmetics should be put on a clean skin and not used to cover up dirt, Old cosmetics (two years after its manufacture) should not be used as they can harm the skin.

Clothing: Clean clothes should be worn at all times.

Clothes should be washed daily and dried on a rope in an open area.
The clothes should never be dired on ‘grass or grounds as it may give rise to various skin infections.

The under-garments should particularly be washed everday.

Care must be taken while selecting chothes also.

In summers one must use cotton clothes so that they help in soaking the sweat and give a comfortable feeling to the person.

Hygienic disposal of waste water: Water collections around the houses are a health hazard as they lead to mosquito breeding.
Collection of waste water gives rise to unpleasant odours.

Waste water can be safely disposed of by constructing — (i) soak- age pits: (il) kitchen gardens.

है Soakage pits provide a hygienic method of disposal of waste water as they are cheap and easy to construct.

Asoakage pitis a dug out space filled with stones or over burnt bricks, The waste water from the house is led through a drain to the soakage pit which seeps gradually into the ground.
This reduces the danger of polluting wells in the-vicinity.

A field level worker can help the community in constructing soakage pits with the help of health worker A kitchen garden can provide fruits and vegetables for improving the nutrition of the family besides providing a hygienic way of disposing waste water from the house.

If the household is small, the amount of waste water is limited and can easily by disposed of by teading lt into a kitchen garden.
Kitchen gardens are easy and cheap to construct.

A field level functionary can help the families to starta kitchen garden with the heip of the agricultu- ral workers in the area.

Disposal of animal manure and solid household waste: Indiscriminate collections of refuse lead to fly breeding, attract rats and dogs, are unsightly, and cause unpleasant odours.

Refuse should not be dumped in drains as the drains become choked and produce stagnant water collections which lead to mosquito breeding.
Refuse should be properly disposed of by composting, burying or burning, Animal manure and the solid household waste can be hygienically dis- posed of by composting.

An advantage of this method is that the resulting compost serves as a useful fertilizer.

The pit should be near the house but away from the water source.

Dig a pit of 4mt.x3mt.x1 2mt.

or 3mt x 2mt..x Tmt.

size.

Instruct the family to fill the pit with layers of refuse and cowdung in the ratio of 3; 1 by volume unit!
the whole content of the pit reaches 30cm.

above ground level.

The uppermost layer should consist of refuse.

Leave 117 the filled pit for 6 months after which the compost can be used asa fertilizer.

When the pitis full, dig another pit.

A fieid level worker can help the families in constructing pits.
Hygienic disposal of excreta: Unhygienic disposal of human excreta leads to disease transmission through flies settling on food, drinking polluted water, eating contaminated raw vegetables and walking barefoot.

In rural areas, the proper disposal of human excreta by the use of sanitary laterines is primarily the responsibility of the house owner.

A sanitary faterine is a safe and hygienic way of disposing of human excreta.

A sanitary laterine is a water-seal type of laterine.
Sanitary laterine must be simple,.

easy to construct with locally availabie materials, cheap, easy to maintain, acceptable to the user, able to previde adequate shelter from the sun, wind and rain and the desired privacy.

A fiekd level worker can assist the households in procuring the materials for constructing the laterine from the Block Development Officer and ensure that the laterine is properly used and maintained.
A sanitary laterine must be maintained in good conditions as follows: — The water-seal should be sufficient.

— The laterine should be cleaned regularly, — The laterine should not be blocked by throwing rubbish into it.

— The laterine floor and super-structure should be kept in.a good state of repair.

— When the laterine pit is full the second pit has to be used.

The filled pit is left for six months after which it is to be emptied and the contents used as manure.
The pit is then ready for use again, Well maintained laterine will have the following characteristics.

The excreta is not exposed to flies and other insects and is not accessible to is not unsightly.

Use of animals.

It sanitary laterine should become a way of life in the community.

is free from any offensive odour.

It Home sanitation: Aclean home leads to good health and the absence of disease.

The house should be cleaned daily.

Storage space, almirahas, walls, ceilings etc.


must be cleaned periodically.

The house must be white-washed oncea year.

The cnaracteristics of a good house in rural areas are as follows: — itis well-built with a tin or pucca roof, — The floors and walls are smooth and can be easily cleaned.

— The house is weil ventilated.

— There is sufficient natural light and sun-shine.

— lt has a sanitary laterine.

— Waste water leaves to soakage pit or a kitchen garden.
— lf the house does not have its own weil there are hygienic arrangements of water storage.

— There is:;compost pit or a place for burying or burning refuse.

— The refuse is collected in covered bins in the house before putting the contents into the compost pits.

— Poultry and live stock gre kept in a separate place away from where the people live.

— The kitchen is free from smoke.

— Fondgrains and other foods are stored properly so that inscects and vermins cannot reach them.
— There.is no over-crowding.

Smokeless chulhas: Smoky kitchens are not only uncomfortable to work in but are a health hazard as the irritation of the eyes caused by the smoke pre-disposes to eye infections.

Besides this, the open chulha consumes more fuel and the smoke discolours and damages the walls.

The smoke nuisance can be avoided by the use of a smokeless chulha in which the smoke is led out of the kitchen through a chimney.

(Fig.
(Fig.

1) The chulha is about 75 cm x 40 cm x20 cm and is built of mud mix with straw.

The chimney is made of clay-pipes 10 cm in diameter placed one over the other and tapering 8.75 cm atthe top.

The cnimney projects beyond the roof by 60 cm and rain water is prevented from entering it by placing a cowl over the outer-end.

The advantages of asmokeiss chulha are | — It prevents the accumulation of smoke in the kitchen which causes irritation of the eyes and eye infection.
— It helps in having a neat and clean kitchen in village home.

— Itis simple and cheap to construct.

— Theconsumption of tuel (firewood or cowdung) in smokeless chulhais _ A field level functionary should help the families in constructing the smoke- less chulhas.

less than in an open smoky chutha., Safe drinking water: Water is another very common source of infection.

If water from unpro- tected source is consumed, it can lead to diarrhoeal diseases.

typhoid, cholera etc.


Water collected from ponds, tanks etc.

which have not been chlorinated should be boiled before drinking.

Boiling makes the water safe.

This is must during the rainy season and when epidemics of cholera and dysentry are around.Wells should be protected from contamination by constructing a parapet and a plat-form around the well, using a cleaned bucket on a pulley for drawing water and not washing clothes and utensils or bathing near the weil.
The chlorinated water tastes different but it is safe a to drink.

Water should be stored in cleaned containers and drawn in hygienic way.

It is the responsibility of the whole community to see that their sources of drinking water are kept clean, Because of the important role ofsafe drinking water In promoting the health of the people, it is discus sedin a separate chapter (Chapter-15) in detail.
Food hygiene: Food should not only be nourishing and attractive but clean and free from any harmful substances if it is to promote health.

When not hygienically prepared, food is infested and if consumed, affects the health.

Food and water can be easily polluted by harmful germs.

In fact, mast of the disease causing bacteria, viruses etc.

use food and water as vehicles for entering into our body, Therefore if foods are not selected in proper condition and stored properly, they get contaminated.
The hygienic handling of food from it is served is, therefore, very essential from the the time-it is produced till 119 E S S S S S S S S Fig.

1: Smokeless Chutha 120 health point of view.

Proper storage of food is importart to protect it from being eaten by rats and from being contaminated by flies and other insects.

Food should be stored ina well-ventilated place.


Cooked food should not be stored forteo long as it breeds disease germs and can cause diarrhoea and vomiting, foods which are to be eaten raw, for example fruits and vegeta- bles, should be washed well with clean water before eating.

All cooked food must be kept covered preferably in a cool place.

Foodgrains need to be stored in closed, rat proof bins.

Eating of foods on road side must be discouraged.


Every time food is handled and before eating, hands must be washed.

Coughing, sneezing over food or handling it with open wounds on hands should never be done as this helps spread infections.

The food hygiene is extremely important in the feeding of children.

Bottle feeding healthy, hygienic habits right from the beginning.
Because of the importance of food hygiene in preventing infections and thus promoting health, the subject is discussed in detail in Chapter-16.

.

Control of insects, rodents and stray dogs : Some insects are responsible for causing certain diseases.

For instance, mosquitoes cause Malaria and Filariasis (Elephantiasis), flies spread Chol- era, Typhoid, Dysentery, Diarrhoea, Trachomaetc., fleas cause Plague and sand flies cause Kala-azar.

It is, therefore, essential to prevent breeding of these insects.
Cleanliness of houses and surrounding is important to pre- vent menace of these insects.

Some of the points for consideration for preventing the breeding of different insects are as under: Mosquitoes: Removing all stagnant water coliections for example in pot holes, tins or old tyres, and using spraying and larvicidal measures.
Flies: Most important fly control measure Is the elimination of breeding places, which can be done by improving the sanitation, Garbage, waste food and other refuse of the house should be stored in bins with lids.

It should not be thrown outside the house or in the neighbourhood.

The refuse should ultimately be disposed of properly, for example, through hygienic compost pits in rural areas.

Open air defaecation should not be allowed, Vomitus and sputum should be properly disposed of.
Kitchen should be kept clean, Use of cut fruits, sweets etc.

which have been exposed to the flies should be avoided.

Doors and windows should have wire-mesh netting.


Use of residual insecticides should be minimal as they pollute our environment, Fleas: By exposing bedding to sun-light, keeping domestic animals and poultry clean, preventing rats from coming near human habitations, and using insecticides wherever possible- Sand-flies: By preventing crevices and cracks in walls and floors by filling and plastering.
Besides consuming and spoiling food, rats carry serious diseases such as Plaque, Rats breed very rapidly, It is, therefore, necessary to control the rat population by properly disposing the refuse, storing food and foodgrains in rat proof containers and poisoning, trapping or killing the rats.

Stray dogs are hazardous because they bite and they can carry rabies.

There is no cure for rabies and therefore it is essential that stray dogs are killed.
Domestic animals should be prevented from coming into contact with stray dogs and jackals 121 Chapter 15 SAFE DRINKING WATER Water covers three quarters of the earth's surface.

The existence of water on our planet (in combination with air, food and energy) has been responsible for our existence, No life is possible without water.
Even withso much water floating on the earth’s surface, getting adequate supplies of water that is fresh, clean and safe to use for drinking, cooking and washing is one of the most pressing problems that faces humanity.

This is because most of the water on the earth is salt water in oceans Only 3% of the total mass ts fresh water, and avery small part of this is accessible.

The relatively polluted and dangerous small amount of fresh water available is to use.
The importance of safe drinking water for the well-being of human beings and how the same could be achieved is discussed in this chapter under the following sub-heads: often — Importance of safe drinking water.

— Sources of contamination.

Water related diseases.

Methods of purification of water.

| Importance of safe drinking water: Water, which is free from harmful micro-organisms (germs), and is patat- able, is known as potable waterar safe drinking water.
The necessity of safe drinking water supply in the homes and place of work can never be over emphasised.

Water Is essential In food preparation.

It is used to wash food belore cooking, toactas a caoking medium and to clean containers of food before and after preparation.

Water is the most important beverage.

It is, therefore, essential that all water meant for drinking and cooking purposes is free from harmful bacteria, Water used for making ice must also be potable since it may be added to cold drinks.
Contaminated water is dan- gerous to health and source of diseases like Diarrhoea, Dysentery, Gastroenteritis, Cholera, Typhoid, Para-typhoid and Jaundice.

Waier is available frorn many sources.

In the hills, water is available from Streams, lakes and springs and in the plains from rivers, wells and lakes.

Rain water collects in tanks ard ponds.

In cities and towns, water is availa- ble through taps.

But all water is not safe to drink.


Apart from disease causing germs, water may also contain dissoived salts or minerals which may make it unpalatable.

The rain water may collect germs and dust frem the air while rivers and lakes get polluted from the industrial wastes and 122 discharges into that water.

Water from deep wells and springs is safe to drink provided it is prevented from pollution from the environment.
Incities and towns, the tap water available through the piped water supply is the safest to drink Sources of Contamination: Source of contamination of water is through the seepage of sewage.

The pollution may be accidental or caused by the uncontrolled disposal of sewage and cther liquid wastes, industrial wastes etc.

containing 2 variety of pollutants, The deliberate spreading of chemicals on the land to increase crop yields is another cause of pollution.
Sewage can be a carrier af many pathogenic bacteria.

Persons suffering from enteric diseases and the healthy persons who may be "carriers" of certain diseases contribute to the presence of bacteria in sewage.

When the disposal of sewage is not paid much attention to,as is the case in the rural communities where human excreta isdeposited near shallow wells, ponds oreven rivers, contamination from this source is widespread.
The contami- nation of water by pathogenic bacteria, viruses and parasites can be attrib- uted either to the pollution of water source itself or to the pollution of water during its passage from source-to consumer.
The pollutants may include the excretions — faecal and urinary of man and animals, sewage and sewage effluents, and washings from the soil, Water is therefore, contaminated through sewage in one of the following four ways: (i) Through seepage of sewage: lf the wells are very near to the pit-latrinesfor faeces, harmful micro- organisms can pass through the ground and get into the well water, spe- cially if the well does not have an intact lining.
If water is taken from the stream or pond where people bathe or wash their clothes, it may containa large number of micro-organisms.

Sometimes the faecal wasies near the streams may also get into the water thus contaminating it with the harmful micro-organisms.

(ii) Through flies and mosquitoes: In cities, the huge influx of population which results in rapid formation of hutments, dwellings without proper sanitary and water facilities leads toa health hazard.
There is no facility for the drainage of the used water thus encouraging breeding of mosquitoes and flies.

These pests carry and spread pathogens from sewage to nearby localities thus creating health problems.

(iii) Through finger nails: When a person washes himself after passing faeces he may get faecal waste on his fingers, If he then washes his hands in a river, stream or pond that water will be contaminated.
Apart from this, ifa person does not wash his hands properly with soap and water after defaecation, the harmful bacteria in the nails of the fingers may contaminate the water that he may use for drinking or cooking.

123 (iv) Through ———) in water pipes: Maintaining a positive pressure in all pipelines is one of the difficulties faced in big cities.
If the pipelines have become very old and the continuous flow of water is not there with a positive pressure, there is a possibility of seepage of bacteria from sewace into the water pipes.

Water related diseases: Although water is life-giving, it also often transmits disease.

Water- related diseases are the leading killers of infants and children, An estimated five million infants, every single year, die from intestinal diseases before their first birthday.
One of the symptoms common to most water-borne and water-washed diseases is Diarrhoea, Climate, geography, culture, sanitary habits and facilities, the quantity and quality of local water supplies and metheds of waste disposal all affect different groups of water related diseases in different ways.

One group may depend on changes in water quality, another on water's availability, and another on indireat effects of standing water.
There are five general categories (occasionally overlapping) of water- related diseases: (i} Poor sanitation contributes to ‘water-borne disases’ which include hepatitis.

In these cases, polluted water acts cholera, typhoidand infective as a passive vehicle for an infecting agent.
(ii) Lack of water, poor personal hygiene and lack of proper waste disposal contribute to a large group of ‘water-washed diseases’ including scabies, leprosy, typhus, paratyphoid fever, conjunctivitis and trachoma (a isading cause of blindness).
(iii) Aquatic animais in drinking water can cause ‘water-based diseases’ like guinea worms and urinary and rectal infections, (iv) Diseases with water-related insect vectors, such as yellow fever, malaria, sleeping sickness and other infectious viral fevers, are spread by mosquitoes, flies and other insects that breed in water or bite near It, In these Cases adequate piped water supplies are needed to eliminate the need for people to gather in the infested area.
(v) Diseases caused by water contaminated with intestinal parasites such as hook-worm present in human excreta are prevalent in many parts of the country, Presence of high flourine content in water can cause a disaese called Flourosis leading to skeletal deformities.

The disease confined to 4 States in india in 1960, now affects as many as 10 States.

The main problem is the amount of flouride consumed through water.
Methods of Purification of Water: lt is essential that water used for potable purposes is free frony pathogenic bacteria, The best precaution one can takeis to prevent the source of water from contamination with sewage.The water should be taken either from the municipal system or deep well, lt should be stored in cleaned, covered pots andalong handled ladle should be used for taking out the water.

Do notdip your hand while taking out water from the-container.
Hf the source of water is unsafe then the water has to.be purified before drinking.

The two main ways of purification of water are: 124 (i) Boiling (ii) Chlorination Boiled water is safe for drinking.

Boiling kills harmful bacteria present in the water.

Most people do not boil water before drinking.

Therefore, it is very important that the source of drinking water is safe.
The usual way of ensuring a safe drinking water supply is to chlorinate the water source as chiorine is the most reliable disinfectant for large scale use.

Chlorination of water can either be done by the addition of bleaching powder or by the injection of liquid chlorine.

Bleaching powder on reaction with water releases chlorine which is capable of killing pathogenic orga- nisins.

Thus fresh bleaching powder is apowerful disinfectant and kills the germs in water.
A bucket of water (containing about 14-15 litres water) can be purified easily with bleaching powder.

Dissolve one tea-spoonful of bleaching powder in a glass of water (250 mi).

Add 3 spoonfuls of this solution to one bucket of water.

Mix it well and allow it to stand for halfan hour as chlorine takes some time to act.

For purifying the water of a well, 225 gms.


of bleaching powder has to be used fora well of 10 ft. diameter and 10 ft. water depth, In cities and towns, purification of water is done in'water works.

The suspended impurities settle down when the water is allowed to stand in big tanks and aluminium sulphate is added, Further the action of sun-light and the paucity of food results in the destruction of bacteria.

The next stage consists of tiltration through sand.

The filtered water is then chlorinated.


Some of the points for consideration while using well water are: — The well should be cleaned and disinfected before use.

— Prevent the contamination of well after it has been cleaned and disinfected.

— The well should have cement lining to prevent bacteria from seeping through the soil and gaining enterance in the water.
— Build a parapet wall and a platform around the well; and a drain to carry the spilled water away from the weil, Do not allow the surface water to go into the well.

— Do not allow dirty water to stand around the well.

— Do not throw garbage near the well, — If possible cover the well and install a pump to draw water.

— Do notdig pit latrines or garbage pits within 25 ft. radius from the well.

— Bathing and washing clothes or utensils near the well must be avoided.
— Donotuse the contaminated vessels to draw the water.

Clean the bucket before drawing water and do not place it on a dirty surface, — Open wells should be chlorinated once a week Mix the required amount of bleaching powder in abucket three-fourth full of water.

Fix the rope or chain to the bucket handle and lower the bucket containing the solution in the well.

Shake the bucket to ensure proper mixing, taking care that the bottom of the well is not disturbed.
Water from ponds, lakes or canals should not be used.

In case It is unavoidable, the water should be purified before use as follows: — Strain the water through two layers of cloth and allow the water to stand for ashort-while.

The water should then be purified by using bleaching powder or by boiling.

125 S e Chapter 16 FOOD HYGIENE Food isan important vehicie for transmission of communicable diseases.

Food is liable to contamination at any stage from production to consump- tion.
Food hygiene, therefore, implies hygienic practices in the production, handling, distribution and storage of all types of food.

In order to communicate the message concerning food hygiene effec- tively to the community, the subject has been discussed under the following sub-heads: — Importance of food hygiene.

— Food handling.

— Food contamination.


— Practical rules for food sanitation Importance of food hygiene: Food sanitation implies cleanliness In producing, preparing, storing and serving food and water.
Food sanitation is an essential aspect of food preparation, It needs to be emphasised al every stage of food handling and preparation, Some of the items which need particular attention to ensure that food is safe for consumption are a safe and potable water supply, selection of whelesome ingredients and hygienic handling to prevent the entry of narmful and pathogenic organisms, both during preparation and serving.
In addition, all the equipments coming in contact with food should be scrupulously cleaned; the surroundings should be clean and there should be a proper and safe method for the disposal of waste.

Inculcation of hygienic habits would help in preventing foods from being contaminated during handling.

All food either bought from the bazar or grown in one’s own farm would have to be cleaned and prepared for either eating directly or cooking.
The 126 dirt or dust which we find on foods as we buy them can be carriers of spores of micro organisms, Therefore, allexposed food must be washed with clean water before use.

Outer layers, skins of plant material contain thousands of micro organisms and must be washed thoroughly before use.

If any part of fruits and vegetables are bruised these should be trimmed to reduce contamination.

The skin, hair, feathers, intestines of animals harbour a number of micro organisms.
I} is, therefore, necessary to remove these, before animal products are prepared for human consumption.

Food handling: Food comes into contact with human hands during harvesting, storage, preparation and service.

It is important that food handlers be free from any communicable diseases — colds, any other respiratory ailment, cuts or boils, as they may be responsible for transferring these to the food thereby spreading the infection,to persons consuming the food.
Human hair, nasal discharge, skin can also be source of micro organisms.

Therefore, persons handling food, must wash hands with soap before starting preparation, and refrain from touching hair or wiping nose during food preparation, a way of life.

Food sanitation is It can never be over-emphasised.

A number.
A number.

of gastrointestinal disorders, such as diarrnoea, cholera and communicable diseases such as typhoid, septic sore throat, diphtheria, dysentery, etc, are communicated by use of contaminated water or food.

Therefore, it is very important that sanitary handling of food and water is religiously adhered to.

Food handler: Almost the whole responsibility for outbreaks of tood poisoning rasts with the food-handler and therefore his education in food hygiene Is of primary importance.
Proper handling of foods, utensils and dishes together with emphasis.

on the necessity for good personal hygiene are of great importance.

Diseases which are transmitted by food handler are amoebic dysentery, bacillary dysentery, typhoid and paratyphoid fevers, viral hepatitis.

ascariasis, staphylococcal and streptococcal infections, salmo- nellosis etc.
Medical examination of food handler: A preliminary examination at the time of employment, complete with bacteriological investigation of the stool should be done.

But initial and even periodic medical examination cannot eliminate chance of contamina- tion of food for the following reasons: — Most outbreaks are due to illnesses of a transient nature.

Such are not likely to be prevented by periodic examinations.
— Regular examination can only show that the individual is free from disease at the given moment, but cannot ensure that he will not become infective the next few days.

— Time and money are needed on periodic examination to detect a few carriers, 127 A person suffering from हि diseases should be kept away trom food handling.

Carefui watch should be kept for any septic conditions of the hands, face or scalp and discharges trom the ear or nase or for indication of diarrhoea.
Temporary leave from work or change of duties to keep him away from working with food should be granted.

Personal hygiene: Personal hygiene is avery important method for prevention of food-borne infections.

i) Hands: The hands should be scrubbed and washed with soap and water immediately after visiting a lavatory.

Finger nails should be trimmed and kept free from dirt.
Inside the toilet, a notice may be placed reminding the users of the need to wash their hands before leaving, ii) Hair: Head covering should be provided, particularly in case of females to prevent hair falling on to the food.

lii) Overalts: All (ood-handlers should wear clean, white overalls while at work.

Overall should be replaced at frequent intervals.

1४) Health:Orai hygiene should be practised.

Any cut, burn or raw-surfaces should at once be cleaned and dressed.
v) Habits: Coughing and sneezing in the vicinity of food, licking the fingers before picking up an article of food, smoking near food should be avoided.

Food contamination: There are various sources of contamination of food.

In order to protect the food from getting contaminated at all points along the food chain, itis necessary to know the sources of contamination of food.

Food may be contaimated if the: 1) Water used for washing or cleaning is not potable.
2) Soil adhering to foods grown close to groundisnot completely removed.

3) Containers or utensils used for storage and preparation are not clean.

4) Personne handling fsod have unhygienic habits.

§) Personnel handling foad suffer from communicable diseases.

6) Food is not transported properly.


Food has not been refrigerated during transit and proper precautions for preventing secondary contamination through contact with germs or carriers have not been taken The han- diing of the food has not been hygienic in butchers’ shops, bakecies, retail dairy shops etc.

7) Food has been contaminated during processing.


8) Animals themselves are diseased or are merely the passive carries of organisms infectious to man, The foods most commonly responsible far food-borne diseases are milk and milk products, meat, fish and fish products, eggs, salads and other vegetables eaten raw.

Foods of animal origin are favourable bacterial cultu- ral media.
If contaminated with pathogenic bacteria, they readily produce and convey large doses of toxins or pathogenic bacteria which cause gastroenteritis and sometimes neurological disorders.

Staphylococcal tox- ins are probably the commonest cause of food poisoning.
Once food is contaminated, bacteria can multiply at fantastic speed, If toxins are formed 128 these are not eliminated by heating When cooked foods are cooled to room temperature, bacterial multiplication can proceed rapidly, even for a time after placing in a refrigerator, because it takes some time before the central portion of the food becomes too cold to prevent bacterial multiplication.
The consumer should take particular care to purchase only uncontami- nated foods, remembering the hazards of contamination by flies and of purchasing meat or fish which are not fresh even though they may look clean.

This underlines the need forstrong programmes of heaith education to support food hygiene programmes Vegetables are liable to contamination during both production and mar- keting, with faecal-borne bacteria and amoebae and other parasites.
Thisis particularly true where human night-soil is used as a fertiliser in their production.

Multiplication of bacteria in foods is minimised by heating, drying, salt- ing, pickling (in vinegar), canning with sterilisation, cooling to 10°C or lower, freezing and irradiation with ionising radiations.

Bacteriostatic or bactericidal chemicals are sometimes permitted on foods to meet special problems, but are only allowed within strictly defined limits.
Fruits which are peeled before consumption are safe Fruits which are likely to be eaten unpeeled and which are sprayed with poisonous insecti- cides may cause toxic effects to consumer, They should be thoroughly washed to remove spray residues.

it is necessary that all equipments coming in contact with food be kept clean.

This includes knives, meat mincers.

blenders, rolling pins, wooden boards,metal and porcelain dishes, utensils etc.

They should be scrubbed, cleaned with detergent.


and water and then rinsed with potable water.

itis a good practice to see that such equipments are dipped in hot water at 80°C for atleast 30 seconds or more and then allowed to drain dry.

This sanitary step is especially important during epidemics such as infective hepatitis (infec- tive jaundice), cholera etc.

Parts of blenders, mixers, etc.

should be inspected after cleaning to ensure that there is no food material left over.
If allowed to remain, they could allow harmful micro organisms to grow and spoil the food, In villages, itis a common practice to scrub the dishes with ash and then rinse them with water, The utensils and dishes are then allowed to dry in the sun.

The alkaline ash acts as a good agent for killing any micro organisms adhering to the utensils and a sanitary effect is produced by drying in thesun both because of neat and the ultraviolet rays.

One of the common insects contaminating foods is the housefly.
These have minute hair on their legs and thus can de carriers of harmful bacteria depending on where they come from is possible that they may carry faecal matter or othersuch sources of pathogenic bacteriaand deposititon the food.

It Another insect which can also be a source of contamination in the same way as the housefly is the cockroach.

These insects, which usually prefer darkness, have been known to cause diarrhoea and dysentery.
Apart from these two common ones, there are innumerable insects rang- ing from the larvae found in wheat and rice to locusts, which can cause serious damage to food.

Rodents.

which include rats, mice and bandicoots, not only consume large quantities of food, thus contributing to the overall shortage of food in 129 the country, but may also be the carriers of disease such as Plague.
Itis thus essential that preventive measures are taken to exclude the entry of insects and rodents in the house, especially in the cooking and serving areas.

This can be done by: i) keeping the prepared food in cupboards with wire-netting, ii) filling cracks, fissures in the walls and flooring which are usually the places where insects breed and multiply; and ili) covering drains, holes, etc.
with wire gauze so as to prevent the entry of rodents, Thus, the main food contamination threats appear to be — raw food, non-potable water, inadequate domestic sanitary practices, (improper food handling practices, especially of cooked food), and inappropriate storage practices Practical rules for food sanitation: 1, Tie hair neatly before starting food preparation.

Use hair net or cap if necessary.

Wash hands thoroughly with soap and water before starting preparation.

2.
2.

Wash fruits and vegetables, particularly leafy vegetables thoroughly before preparation with potable water.

Boll milk ina clean container as soon as possible after receipt and keep covered.

Empty bottles of milk should be rinsed with water and then kept.

3.

Use potable water in food preparation.

4.

Boil water used for drinking or for preparation of cold beverages, if the purity of water is not guaranteed.

5.

Utensils and equipments used for preparation should be sciupulously cleaned.

6.
6.

Cooked food should be stored covered, preferably in the container in which it is cooked.

7, Left over foods such as rice, vegetables, should be stored either in a refrigerator or kept in a pan of water.

Reheating before use is advisable, 8.

Household wastes including garbage and waste water should be prop- i erly disposed of 9.

Personal hygiene should be observed at all levels.

10.

Anima!
10.

Anima!

foods should be bought fromasate source and properly cooked, Apart from eating-houses and community feeding, the markets are the places where food hygiene is maintained or spoilt.

Some of the principal requirements for hygiene in the market are: 1.

2.

3.

Adequate and safesupply of water for arinking and washing purposes, Adequate space, and sectioning, ventilation and lighting: Floor preferably concreted.

graded and drained; and adequate plumbing, Grains, surface drainage} 4.
Thorough cleaning of food stall counters and floors at leastdaily: 5.

Garbage: regular and adequate collection and storage in covered-bins, and removal al least daily, Sanitary laterines; 6.

Control measures for flies and rats; 7, 8.

Prohibition on sleeping in market stalls 130 Chapter-17 FOOD TOXICITY & FOOD SAFETY Food has a well recognised function.

It is essential for growth and maintenance of health.
But, food can perform this basic function only if itis safe: It should be safe in nature, and free from toxins and such other components like additives and contaminants which may interfere in assimi- lation of nutrients or prove to be potential health hazard.

Every food may not be safe from health point of view.

When is a food fit to eat?

Itis fit to eat if itis free from harmful contaminants, toxins, bacteria etc.

and after consumption the person does not feel sick.
In this chapter of food toxicity and food safety, factors responsible for their occurrence and mea- sures required to be taken have been discussed under the following sub-heads: — Food toxicity.

— Kinds of food toxins.

— Health consequences of chemical contaminants and toxicants in food.

— Factors affecting the safety of food.

— Sugyested ways to food safety in general.


Food toxicity: Food toxicity is the condition precipitated by consumption of unwhole- some food which either contains toxin, chemicals or has become contami- nated.

In order to prevent toxicity in food; it is necessary to understand the nature of toxins, their sources and the safety precautions.

Kinds of food toxins: Food toxins may be classified as per the case of its occurrences in the following groups viz.

A, Natural texins.

B.


Accidental chemical contamination or pollution.

A.

Natural toxins: Toxins may be naturally present in food.

It ‘can be a component of food present in it, occurring naturally.

It may be grouped into the following groups in general: 131 (a) Inherent — Usually present in the food = affects every one if they eat enough, e@.g., solanine in potatoes, lathyrus sativus in kesari dal.
(6) Toxins resulting from abnormal conditions of animals or plants used for food — For example, neurotoxic mussel poisoning, honey from bees feeding on Rhododendron or Azatea nectar (c) Consumer abnormally sensitive: Constitutional e.g.

coeliac disease from wheat gluten, favism from broad beans, allergy to particular food or drug-induced, e.g.

cheese reaction, (d) Mycotoxins: Food, mouldy or spoilt, e.g.

aflatoxins in groundnuts from aspergillus flavus.


(e) Contamination by pathogenic bacteria: Food may not appearspoilt but eating such foods may result in acute illness, usually gastrointestinal caused by toxins produced by Staphylococus aureus or clostridium botulinum.

8.

Accidental chemical contamination or pollution: Food may become toxic due to accidental chemicai contamination or pollution, Sometimes, the use of unintentional food additive may also become a reason for food hazards.
The accidental chemical contamination may be classified in the foliowing groups, namely:— i) Unintentional additives: Man made chemicals used in agriculture & animal husbandry, For example, fungicides on grain, insecticides on fruits, antibiotics or harmones given to animals.

(\i) Environmental pollution: For example, chemicals, wastes, organic mer- cury or radioactive fall out can affect any stage of food chain, (iiiintentional food additives like preservatives, emulsifier flavours, colours etc.
: Some of the additives have been in use for centuries, many are naturally based and used in small amounts, the most thoroughly tested and monitored of all chemicals in food, Yet when these are used in quantities more than recommended, prove to be hazardous.

Health consequences of chemical contaminants & toxicants in food: Various chemicals, harmful or otherwise may pe incorporated intention- ally or unintentionally during the production, processing, storage, distribu- tion and consumption of food.
Pesticides and herbicides, necessary to contro!

insect and fungal pests in agriculture and ectoparasitos in anima!

husbandary, may be harmful when improperly used.

Excess amounts of certain growth stimulating drugs and harmones may be found as residues in edible animal tissues and plants, Environmental contaminants can also prove a health hazard.
Some of the specific consequences of the food toxicants are: (a) Chemicals: The illegal use of chemicals in food can mask quality, disguise deterioration or constitute a deliberate adulteration.

The adul- teration of food can, in certain circumstances, be very harmful to health as well as frauding the consumer as regards to the identity or value of the food.
(b) Plant toxicants: Toxicants in edible plants and poisonous plants resem- bling like mushrooms, certain wild green piants are important causes of ill-health in many areas of the worid.

In some places, poorer sections of 132 the population eat grains known to be potentially toxic like lathyrus sativus in order to still their hunger.
Mycotoxins: Mycotoxins are a group of toxic chemical compounds pro- by Certain strains of a number of species of fungi when they grow under favourable conditions on a wide variety of different sub-states.

As their generic name implies, these compounds are toxic to man and animals causing diseases collectively known as mycotoxicoses.

Fungi capabie of producing such compounds are usually described as toxigenic.
Because of the formulation of mycotoxins, the general problem of mould growth on food has extensive agricultural and economic implication beyond obvious food spoilage.

This is of particular importance in connection with the development of protein-rich foods based in part on peanuts, cottonseed, soya and other plant sources for use in alleviation of protein malnutrition.

The most extensively studied mycotoxins are aflatoxins which are gener- ally resistant to normal processing technique.
Some mycotoxins are power- ful carcinogenic agents and other cause ergotism, alimentary toxic alenkia and other diseases, The control of mycotoxins requires that mould contamination in food and feed should be prevented or reduced to harmiess leveis.

This basically involves establishment of good harvesting, drying, handling, storage, transportation and distribution procedures.
Food borne diseases and classification of food borne illnesses have been indicated in tables | & Il Factors affecting the safety of food: The type of food systems by which food is produced, processed, distributed, prepared & consumed is related to the stage of development, level of income & socio-cultural characteristics of communities.

The food system can be broadly divided into three important categories, namely: (a) Low income rural system.

(0) Low income urban system, (c) High income system.
Each system has its own particular food safety problems and require different remedial approach, (a) Low income rural system: Since most of the food utilised in this system is produced locally, the primary areas of concern are: i) The frequent contamination of grains and pulses during harvesting by soil borne spores of organisms such as Bacillus cereus and Clostridium perfringens.
ii) The contamination of food at the time it enters the home possibly through the use of non-potable water in growing or washing vegetables and fruits before eating as raw foods.

lili) Poor practices in drying, storing, handling and preparing the staple food, and/or use of non-potable water.
The main food contamination threats appear io be raw food, non-potable water, inadequate domestic sanitary practices, (practically improper food- 133 handling practices, especially of cooked food), and in-appropriate storage practices.
(b)Low income urban system: The basic areas of concern of this category are: i) The growth of centraiised markets as primary distribution points for food supplies purchased from large number of smail farms in the rural areas and transported by assembly traders to the urban areas.

ii) The greater tendency for cereal staples to be ground, partially pro- cessed or cooked before the retail stage, and for developing separate marketing channels for these commodities.
iii) An increase in the quantity of simple processed or prepared food for consumption inside or outside the home and mostly produced by rela- tively small scale processors.

iv) Aretail system consisting of multitude of small scale traders, itinerant vendors and retail outlets, each selling small quantities of raw, pro- cessed or ready-to-eat foods.
(c) High income systems: As income rises, the percentage of available income spent on food declines, People can afford a more varied diet and are likely to purchase more semi-processed or processed foods that incorpo- rate variety and reduce time spent an food purchase and preparation.

Itis because of these reasons that the population falling in this category is more dependent on industrial processing techniques.
The potential prob- lem thus arises from failures in the quality (and safety) control of pro- cessed and prepared foods by the industrial food processors or mass caterers.

Suggested ways to food safeiy in general: Food hygiene covers all measures necessary to ensure the safety, whole- someness, soundness of food al all stages from its growth, production or manufacture, until its final consumption.
Because there are so many sour- ces from which disease agents may be transmitted to food and because food can become.easily contaminated by these organisms, food must be protected at all points along the food chain, from the time it is produced unitl it is served to the consumer, All the measures or precautions practised in applying the principles of food protection, can be classified into 4 basic rules: i) Keep food clean ii) Store in cool place ili) Serve food hot iv) Don't keep food in dirty places in particular, the following can ensure food safety and prevent tood borne ilinesses.
A.

Personal hygiene: “Human element’ is the single most important factor in the control of food - borne illness.

Every individual must follow some routine habits like hand washing throughout the preparation of meals to avoid possible risk of contamination.

Cuts, sores, burns and ocils sh ald always be covered with water proof bandages because they aiso czy food poisoning bacteria.

134 Food service workers in food service establishments must be free from all communicable diseases.

B.
B.

Food must be secured from approved sources: Since food come from different places, one has to ensure that the incoming food is safe for consumption.

1.

Water supply/potable water: Water, though not considered as food yet.

plays an important role in human nutrition.

When contaminated, it transmits disease through the pathogenic organisms it contains or through the utensils and equipment washed in it.

Thus, it is necessary to use safe water for consumption.

2.
2.

Safe sources of food: Most foods support microbiological growth.

The consumers should take particular care to purchase only uncontaminated foods.

Milk and milk products should be pasteurised.

Meat and poultrv should be slaughtered and processed in sanitary conditions.

It should bear tne label of an official inspection agency.

Canned food should be processed in authorised food processing plants.

C. Store foods properly: Foods are not usually prepared and served just after purchase.
It is Is stored tor varying lengths of time and in a variety of conditions until It prepared for service, thus, subjecting to contamination ina variety of ways, 1.

Protection during dry storage: Foods placed in a dry storage should be arranged and stored so that the food placed in first is used before newer incoming supplies, thatit, “Firstin, First out”.
All foods should be stored off floors on pallets and shelves and, if possible, away from walls thus preventing it from being contaminated by insects or rodents or from flooding.

2.

Avoid wet storage of packaged food: Never store packaged foods like cartons or bottles of milk and juices in iced water to keep them cold.

Water in which the container is stored is contaminated through use and seepage through leaks may aggravate the problem.

3.
3.

Remember that temperature has relation to food protection: Food, moisture, temperature and time are some of the requirements for the growth of organisms.

There is little opportunity to control the first two 135 and so prevention of contamination depends on controlling the tempera- ture of food to control microbial growth.

Temperature Guide (°F) To serve hot foods, store while serving above 140°F (soups, gravies meats etc.)
480 170 160 150 140 130 Some bacterial growth may occur ———: OD DANGER ZONE Most bacteria including food poisoning type will grow rapidly over this temp.

range 100 90 80 70 110 = Ordinary room temperatures may fallin this range.

Do notstore prepared food at room temperature.

NI gs Some bacteriai 50 growth may occur 40 Refrigerate prepared foods to prevent bacterial ‘growth and to prevent food spoilage Store frozen foods at this temperature or below.
2G 20 10 © Toserve prepared cold dishes, keep on ice while serving (Potato salad, chicken salad etc.

Thaw or cook from frozencondition when ready to use.

n S To be sure that the correct food temperature is maintained, use a reliable thermometer Microbial organisms grow best al temperature near that of human body or about 100°F (37°C).

Disease organisms grow over a wider range of temperature in the danger zone where the microbial growth is rapid 1,6.
$5°-140°F (49C-60°C), Therefore food should be stored either below 45°F 136 | or above 140°F (60°C) but not for too long.

Keep food cold so that micro organisms do not grow very well to repro- duce in numbers sufficient to cause illness.

Remember that this tempera- ture or even freezing and refrigeration does not ki!l most micro organisms but only slow down or halt their growth temporarily.

If temperature rises significantly, any organism present in the food begins to grow.
On the other hand, in case food held is at 140°F (60°C) or above, micro- organisms are killed rapidly but are not readily affected when the tempera- ture goes below 140°F (60°C), So, after food is cuoked, it should be kept hot and not just warm, until served.

If it is kept "just warm" on the back of the kitchen range or on the table, rapid microbial growth may occur and out- break of food borne iliness could result.

D. Practice proper preparation of food: 1.


Work with clean hands: Hands must be washed often with warm water and soap to keep them clean.

Though many foods are handied by hands during preparation, prac- tice using sterilized handling utensils for food like forks or tongs.

This isnot only appealing but shows concern about health of the consumer.

2.
2.

Use clean utensils: Clean contact surfaces of tables and equipments, Prompt and thorough washing and sanitizing between uses prevent outbreaks from occurring.

3.

Clean raw fruits and vegetables: Fruits and vegetables are grown and handied in many different condi- tions, Soaking, followed by thorough washing in running water, is usually sufficient to remove most chemical contaminants or disease organisms.

4.
4.

Avoid left overs: Food kept for along time between preparation and serving is more likely to cause diseases.

If leftover prepared foods (unserved) are to be kept, adequately protectand refrigerate them.

Serve hot again by rapidly reheat- ing to above 140°F (60°) to boiling temperature.

5.
5.

Practice healthy habits: Habits of individuals are most important in providing proper protection during food preparation, Therefore, habits as placing fingers in the hair, picking at the nose, or coughing and sneezing are to be avoided when preparing food, 6.

Cook foods properly: In cooking see that all parts of the food reach the proper temperature.

The principles that apply to cooking food aiso apply to reheating of food.

137 7.
137 7.

Store and display food properly: Cold foods ona serving line must be maintained at a temperature of (4°C) or below and not that of the ice or cold plate on which the food is placed.

Hot foods on a serving line must be maintained at 140°F (60°C) or above.

This must be the temperature of the heating unit at which the food is held.

Serving of foods should be done with an appropriate utensil.

Pack foods properly.


Packaged foods that have been opened once, should not be offered for resale or re-service.

E. Observe proper practices for refrigeration of foods: 1, Foods must be refrigerated at all times except during the period of actual preparation or serving.

Hot foods removed from the range should be retrigerated immediately after cooling to shorten the time itis in the danger zone.

2.Thaw frozen foods quickly.

Frozen foods should be kept frozen atall times.


They should be kept in the freezer of the retrigerator until thawed and never at room temperature.

For quick thawing, place the food in a clean plastic bag and suspend in running (70°F 30°C or less) tap water and cook promptly.

3.

Arrange food in containers in refrigerator.

Store foods in shallow pans or in smaller round containers to cool rapidly.

A good ruleisto make certain that the distance to the centre of the foodisnot more than 2 inches.
This means that shallow pans.or even round contain- ers should be filled not more than 4 inches deep.

Stir the food occassionally to bring warmer parts of the food mass closer to the surface to dissipate heat rapidly, Place containers in the refrigerator in a manner that permits air circula- tion around each container, Cover all containers in the refrigerator to prevent contamination trom the shelves and among the foods in the refrigerator.

Clean refrigerator thoroughly with a detergent.


F. Practice hygiene at home and at commercial and community feeding establishments.

Proper ventilation, lighting, floors, adequate supply of safe drinking water and water for washing drains, surface drainage, regular collection and storage of garbage in covered bins and removal at least daily, sanitary laterines, control measures for flies and rats are pre-requisite and should invariably be observed.
G. Observe legislation procedures: To support proper investigation in matters of food sanitation, ordinances and regulations -are promulgated.

1.

Personnel: Supervision of food premises by health inspectors attached to health centres to monitor overall environmental hygiene programming.

138 2.

Legislation: Prevention of Food Adulteration Act covers food standards.

The Preven- | of Food Adulteration Act, 1954 (PFA Act) came into force from 1st June, 1955.
The objective of the Act is to provide consumers pure and wholesoine food.

Under the provisions of the Act, PFA Rules, 1955 have been pres- cribed, The rules inter-alia provides for regulatory provisions for ensuring food safety, The PFA Act, 1954 and Rules 1955 defines the terms, food, adulterate etc.

"Food", under the provisions ot the Act means any article used as food or drink for humanconsumption other than drugs and water.
It also includes flavouring matters or condiments or any preservatives, food adjuncts etc.

Salient features of the PFA Act, 1954: 1.

Prohibition of import of adulterated, misbranded or without licence orin contravention of PFA Act or Rules .

Prohibition of manufacture, sale, without licence or in contravention of m ™ provision of Act or Rules.

.

Regulates use of additives, colours, flavours and other processing aid, .
Packaging and licencing of foods, Conditions for licence for sale, stock and exhibit.

.

Use of pesticides in foods.

Regulations concerning solvent extraction of olls and edible flours, .

Prescribes minimum standards for food products.

.

Prescribes manner of analysis of food, procedures for actions .

Defines power of Central and State Governments.

.

Prescribes penalties.


o O S A N M O O — > _ — = Punishment under the PFA Act (Section 16): Sale of adulterated food is an offence punishable with six months impri- sonment, which may be extended upto 3 years with a fine of not less than Rs.

1000.

— If the adulterated articte is of injurious nature, the punishment may rise upto 6 years imprisonment with a fine of not less than Rs.

5000.
5000.

— lfan adulterated food is likely to cause death or serious injury to body, imprisonment may extend upto life with mimimum fine of Rs.5000.

Food safety is necessary at each and every stage in the food chain for is safe for preserving the quality of the food and for ensuring that it consumption.
Table-| FOOD - BORNE DISEASES The list given below contains some diseases in the transmission of which food plays an essential role, such as in the case of certain parasites where a food/animal is the host or intermediate host.

it also contains other diseases which can be transmitted by the contamination of food as well as in otherways.

139 । .

७ | 1.
139 । .

७ | 1.

Bacterial diseases Causative organism Anthrax Botulism Bacillus anthracis Costridium botulinum Cholera Vibrio cholerae Dysentery bacillary Paratyphoid fever Various species of genus shigella Salmonella Salmonellosis Salmonella Staphylococcal!
infections Streptococcal infections Tuberculosis Typhoid fever Staphylococcus Streptococcus Mycobacterium tuberculin Saimonella typhi Parasitic diseases Amoebiasis Ascariasis Enterobiasis Entamoeba histolytica Ascaris Lumbricoides Enterobios vermicularis Vactor or means of spread Contaminated meat.

Anaerobic growth of spores in inadequately processed canned or bottled food, Contaminated water or food; flies.

Contaminated water or food; flies.


Contaminated food, particu- larly milk, milk products, shellfish, flies.

Contaminated food, particu- larly meat and meat pro- ducts, and milk products Food contaminated from human sources Food contaminated from human sources, Contaminated milk, milk products and meat.

Contaminated water and food particularly milk, milk products and shelifish.

Contaminated food, particu- larly vegetables eaten raw; water, Contaminated vegetables eaten raw.

Contaminated food.
Contaminated food.

TABLE — Il CLASSIFICATION OF FOOD-BORNE ILLNESSES Group Bacterial infections Bacterial toxins Parasites Chemicals Natural poisons Examples of illness in each group Typhoid and paratyphoid fevers Staphylococcal intoxication Saimonella food poisoning Tuberculosis Bacillary dysentery Streptococcal infections Brucellosis Botulism Amoebiasis Ascariasis Trichinosis Mineral poisoning (e.g.

antimony, arsenic, copper, lead,selenium, tin,zinc).

Lubrication oil poisoning.


Mushroom poisoning Gassava poisoning (root or leaves) Fish poisons.

140 Chapter 18 STORAGE OF FOODGRAINS Cereal grain is the symbo!

of life universally.

Grain, particularly rice, occupies a pivotal place in all ceremonies of human life whether it is a birth, death, marriage or any other auspicious occasion.

It is also a symbol of prosperity.


The agricultural production in the country has progressed very satisfac- torily and there has been a phenomenal increase in the production of foodgrains in recent years, especially wheat.

But due to unscientific methods of grain storage, considerable losses occur both in quanuly and quality at farm level.
According to an expert committee appointed by Government of India sometime back, about 9.33% of total production of 141 foodgrains is damaged during post 7 These storage losses are much more at farm level where about 70% of our total foodgrain production is stored.

These traditional structures are neither moisture-proof nor rat proof.

Besides this, most of these traditional structures are not sutiable for carrying out effective fumigation.
Thus it is not only nessary to increase the agricGltural production but also to harvest, store and distribute the grain with least possible losses.

Various aspects of storage of foodgrains are discussed in this chapter under the following sub-heads: — Post harvest handling.

— Causes of storage losses.

— Control of pests.

— Precautions to be observed while using pesticides.
Post harvest handling: Some of the basic requirements are:— — Check the grain in the field after harvest to make sure that the grains are free from insects and diseases.

— Cleaning: Remove the foreign matter by properly sieving the foodgrains.

— Drying: Dry the high moisture grains; otherwise high moisture will lead to spoilage during storage.

— Cooling: Cool the grain after drying before storing it.

Preventive measures during storage of foodgrains are enumerated below.
i) ii) iii) iv) v) vi) Vii) Propercteaning and drying of the grains before storage i.e.

the foreign matter and broken grains, as far as possible, should be removed and moisture content of the grains should be brought down to 10-12% as the grains with a higher moisture content, if put in storage, generate heat and develop musty odour, discolouration and lump formation.

It also attracts attack of fungi and insects, thus, becoming unfit for human consumption.
A rough idea to know if the grain is dry enough for proper storage can be had by putting it between the teeth.

If it gets pressed, further drying is necessary.

If it only cracks, may be considered fit for storage.

To avoid condensation of moisture, dried grain should be allowed to attain room temperature before storage.

Selection of suitable storage structure or receptacle which should be moisture, rodent, bird proof and can be made reasonably airtight.
Collection of all the debris, webbings or refuse from the storage struc- ture/godowns and burning them.

Bird and rat proofing by way of providing 20 gauge 1.25 cm, diameter wire mesh onall the ventilators and windows.

Entry of rats should also be prevented by plugging the rat holes with pieces of glass, stones and mud and cement; by fixing metal sheets of 20 guage to the doors of storage premises upto 12" from bottom, leaving no gap between floor and sheet.
Repair of all the cracks, crevices of the storage structures/godowns with mud or cement plaster and white wash of storage compartment with lime.

Use of dunnage like wooden crates, bamboo mats or polythene sheets for protection from ground moisture.

Provision of proper aeration in the case of large scale storage and hermatic conditions if the stocks are held in small containers.
142 viii) Regular fortnightly inspection helps in timely detection of deteriora- tion of grain in storage by insects, moisture etc., and for taking timely curative measures.

Causes of storage losses: During storage the grains may be affected by abiotic agencies such as moisture, temperature and may be damaged by biotic agencies viz.

insects, rodents, birds and micro-organisms.


A. Ahiotic factors: (i) Moisture and its significance in storage: Moisture content is basically the weight of water which can be removed from the grains by drying without bringing any change in the composition of foodgrains.

High moisture content in grains reduces the viability and the bulk density thus grains occupy more storage space than dry grains.
It also accelerates the rate of chemical and physical changes, growth and development of all the organisms attacking the stored grains.

When the insect population is rapidly built-up at certain places in the bulk grains, heat is generated due to incresed respiration of insects and the grain temepature is increased in bulk grain.

This is known as dry heating of grain.


Grain under very damp conditions accelerates rate of the mould growth with the result that the heat is produced which raises the temper- ature from 43°C to 66°C and moisture content trom 14% to 18%.

This is known as wet heating or damp grain heating.

(ii) Temperature: Temperature plays an important role in the safe storage of foodgrains.

When it rises above 66°C.

not only germination is arrected but giuten value is also reduced.
The optimum temperature for most of the stored grain insect species lies between 29.4 - 32.°C.

Stores cooled to 10°-15°C.

by mechanical refrigeration would, therefore, be a highly effective means of combating insect infestation problem.

B. Biotic factors: Insect pests of stored grains: {i) Among the biotic pests of stored grains, insects are the most serious enemies.
They attack the man’s food during storage thus cause weight loss; food loss; quality loss (weevilization, germination loss, contamina- tion by their excreta and fragments}.Some common stored grain insect pesis are: rice weevil, grain borer, red flour beetle, khopra, almond moth, saw toothed grain beetie, grain moth etc.

.

(ii) Rodents: Rodents multiply fast and breed throughout the year, They contami- nate the grains with their excreta, hair and urine and transmit a number of diseases in human beings.
Common species of rats found are: 1.

Rattus rattus (black rat or roof or nouse rat) 2.

Mus musculus (House mouse) 3.

Rattus norvegicus (Brown rat or Norway rat) 4.

Bandicota indica (Larae bandicoot) 5.

Bandicota bengalensis (small bandicoot) 143 |.

काका । r (1) Birds: Birds mainly damage the foodgrains in field, threshing yards and CAP storage.

But some birds also damage the foodgrains in ware- houses in which windows, ventilators and other openings for entry are there.
Crow, mynas, pigeons, house sparrow and parrots are the com- mon birds which damage foodgrains in threshing yards and CAP or warehouses.

Grains spilled during handling in and around store attract the birds, The birds also contaminate the food with their droppings, feathers and dead bodies.

The droppings carry major food poisoning bacteria (salmonella), Wire meshing of windows and other openings (3/4") and use of thick black polythene strip (P.V.C.
curtain) on the enterance of godowns can minimise bird problem.

In threshing yards and CAP storage mechanical bird scarer may also be used.

(iv) Micro-organisms associated with foodgrains: The effect of micro-organisms (mould, yeast and bacteria) in the field of grain storage is considerabie.

Their presence in foodgrains can bring about loss in weight, reduction in germination, bio-chemical detertora- tion, discolouration, heating and production of mycotoxins (Aflatoxin, ochratoxin etc.)
which may cause Hepatoxins or liver poisons, liver etc.

Aspergillus and Penicillium species are important storage cirrhosis fungi.

Foodgrains stored at high moisture content may be infested with storage fungi.

Temperature between 10°C-14.4°C retards the growth ot storage fungi.

Coniro| of pests: \t includes the use of insecticides and rodenticides for the safe storage of foodgrains.

Inspite of the precautions discussed earlier deterioration is likely to stast unnoticed.
A watch is, therefore, needed and fortnightly inspection is a must for the stored grains, whether in bags or in bulk.

Any damage causing factor noticed in these inspections should be immediately dealt with.
Presence of insects can be detected by presence of (a) webbing, (b) cocoons, dead or living insects, (c) weevilled grains, (d) white powdery material in patches on the bags, or floor (e) heating and general rise in the grain temperature, Fumigation of grains: The most effective method of checking insect development in the grains has been fumigation i.e.

using a volatile chemical which kills the insects through its vapours but does not affect the grains in any way.
Ethylene dibromide (EDB) is one of the most toxic fumigants for insects: The use of EDB ampoules has been found suitable for fumigation of grain stored in small quantities in household structures that can be made reason- ably airtight.

This fumigant, whichisinliquid form, is available in glass ampoules of different sizes.

The individual ampoules are available in sizes of $ml, 10 mi and 15 mi, at reasonabie prices.
The size and number of EDB 144 ampoules needed for fumigation of different quantities of grains are given below:— ५ Quantity of grains (In quintats) 1 2 6 10 20 Size of EDB ampoule No.

of ampoule 3011, 6 mi.

6111, 10 mi.

15 mi.

1 1 3 3 4 For paddy, however, 5 ml.

is required for one quintal.

Procedure for fumigation: For small quantities of grain, the ampoule is inserted a little below the surface of the grains and broken by exerting a little pressure with stone or wooden handle.
Thereafter the structure is made reasonably airtight by sealing it with mud plaster and polythene sheet.

It is desirable to do mud plastering of storage structurein advance leaving only an opening at the top for inserting the ampoule (s).

In large quantities of grains, the ampoules have to be distributed in the grain mass.

One of the methods is by tying ampoules 60 cms.


apart to a bamboo stick, and inserting into the bulk of foodgrains after breaking each ampoule separately at the time of pushing it into the grain mass.

The storage structure thus sealed should be left undisturbed for a period of seven days or as long as the grain is not wanted.

After seven days, the grain can be taken out of the storage structure whenever required.
However, before using this grain it should be aerated well fora few hours until there is no smell of the fumigant.

Rats and their control: Rats not only eat the grain and other food, but also spoil much more by leaving their excreta and hair on to the grain.

This is injurious to health of those who eat such contaminated grain, Losses due to rats are considerable.

The rodents can be easily controlled by using multiple and/or single dose poisons.
Multiple dose poisons: Rats can be fed directly on the bait of ready to use type available in the market, otherwise bait can be prepared at home and used.

The bait can be prepared in the following manner: &@) b) c) d) Flour (cereats/millets) -450 gms.

(4 tea cups full}.

Sugar or Jaggery — 15 am (3 teaspoon full) (in powder form) Any edible oil — 10:gm (2 teaspoon full), Anticoagulant — 25 gm (5 teaspoon full).

The four constiutents are mixed thoroughly in 2 container.

There is no need of mixing water.


This is sufficient for 3-4 roomed house.

Prepared bait material (approx.

500 gm.)

is kept in 4 shallow improvised vessels (bait container) to facilitate rat feeding, on ratruns, dark piaces where rats could consume bait without disturbances even during day time.

Consumed baits should be replenished every alternate day for about 21 days.

145 | dose poison: Zinc phosphide can be used at two per cent level In baits.

To prepare 100 gms.

of poison bait, 96 gms.


(3/4 of tea cup) of bait material like crushed wheat, maize, bajra, broken rice etc.

2 gms.

(1/2 tea spoon) of any edible oil and 2 gm.

of zinc phosphide should be mixed well with a wooden spoon Fried material, cooked rice, bread and chapati crumbs can also be used for the preparation of poison baits.

As zinc phosphide baits often induce bait- shyness in rats, it is advisable to adopt pre-baiting to induce the rats to the baits.
Unpoisoned baits at selected places should be placed for atieast two days.

By observing the intake of bait by rodents, best baiting points are selected for putting about 25 gms.

zinc phosphide poisoned bait at each nlace on thira day at night Precautions to be observed while using pesticides: All the pesticides are very poisonous chemicals for human beings, anim- als and pets.

Therefore, great care and precautions should be taken in their use.
These should be used by trained persons as and when required, All pesticides should be properly labelled and should be stored under lock and key away from the reach of children, animals and pets.

Hands should be thoroughiy washed with soap and water after using pesticides.

In case of poisoning, physician should be called immediately.

Some of the precau- tions are listed below:- — Danot use any pesticide if its container does not bear proper label.
The manufacturer's instructions supplied with the container should be read thoroughly and followed strictly.

— Pesticides are toxic substances which are harmful to human beings also, Hence, use of pesticides, particularly fumigation operation, should be undertaken only by trained personnel.

- Do not mix two or more pesticides for use without formal recommendation.

— Do not smoke or eat anything while using the pesticides.

— Firsi-aid box should be kept ready at hand while using the pesticides.
In case of any accident, competent medical authority should immediately be consulted, Information about symptoms of poisoning and the ante- dotes recommended for different pesticides should be kept handy for reference by the local medical authority.

— Solutions of insecticides and bait of rodenticides should be prepared in open and dry places — Dead rats as a result of poison baiting and left over of poison bait should not be thrown outside the houses/godowns.
They should be burried deép in the soil to avoid secondary poisoning.

Similarly, empty contain- ers of pesticides should not be used for alternate domestic purposes.

— Aluminium phosphide tablets should not be used during rainy/wet days.

— No insecticide should be directly applied on the foodgrains.

Grain con- taminated with insecticides and showing residue above the tolerance limit should not be used as food or feed.
— Hands, face, feetand clothes should be washed with sufficientsoap and water after handling the pesticides.

— Do not biow clogged nozzles with mouth to make it function properly.

— Donotstore pesticides with the food-stuffs.

Store them in cool and dry places under lock and key away from the reach of children and pets.

146 Chapter 19 CONSERVATION OF NUTRIENTS DURING FOOD PREPARATION Food passes through various processes from the time it is produced till it '$ consumed.
In order to derive maximum nutrients from the food that is produced or purchased, it is essential that care is taken at every stage of food preparation to conserve the nutrients present in food.

Ways of conserv- ing nutrients in various kinds of foods during preparation and cooking are discussed under the following sub-heads: — Need for conserving nutrients during food preparation and cooking.

— How to minimise the loss of nutrients during the cooking of cereals.

— Proper handling and cooking of pulses.


— How to cook veyetables.

— Certain tips about the fruits.

— Cooking of eqgs and flesh foods.

— Storage of perishable foods, Need for conserving nutrients during food preparation and cooking: Cookery is not only an art but also a science because cooking on scien- tific lines can minimise the loss of nutrients and make the diet more nutri- tious.
Most of the foodstuffs have to undergo a certain amount of prepara- tion and cooking before they are actually consumed.

Cooking involves one of the following processes — wet methods of treatment like boiling, steam- ing and trying, and dry methods of treatment like roasting and baking.

The wet methods of cooking lead to comparatively greater losses than the dry methods.

Good nutrition includes correct cooking methods so as to get the maximum benefit out of the food.
Cooking gives the food a pleasent flavour and taste and makes it pleasant to the eye and easily digestible.

In the case of like certain antinutritional factors( trypsin inhibitorjand improves their digestion.

Since cooking invariably involves exposure to heat, food is rendered safe from disease causing bacteria which get destroyed during the process of cook- ing.
Flesh foods get softened and easily chewable on cooking But over- undesirable substances destroys cooking pulses, 147 cooking is harmful as it leads toa loss of nutrients.

One of the disadvantages of cooking is that it leads to the loss of certain amount of nutrients which are unstable to heat.

The loss of nutrients during cooking happens partly due to the heat treatment and partly due to the preliminary treatment of washing prior to cooking.
Ordinary cooking causes little loss of protein, fat and carbohyderates in cereals, pulses and meat.

In vegetables, however, there may be some protein loss on boiling in water, particularly when saltis used in cooking and the cooking water discarded.

If the cooking water is thrown away, there is considerable loss of mineral salts specially of sodium, potasium and chlorine due to leaching.
Certain amounts of minerals and vitamins are lost during various processes involved in cooking before food is, therefore, important that proper is made ready for consumption.

It methods of handling and cooking food are used so that the losses of nutrients are greatly reduced.
How to minimise the loss of nutrients during the cooking of cereals: Cooking of wheat: Whole wheat flour is more nutritious than the refined wheat flour (maida) because the bran removed in the process of extraction of wheat flour contains the maximum amount of vitamins and minerals than other portions is important to consume the preparations of of the wheat.

Therefore, it either whole wheat/broken wheat or whole wheat flour, The wheat flour is usually sieved before making the dough of it.
Care must be taken so thatthe bran is not discarded after sieving the flour.

Instead, after sieving the wheat flour extraneous matter present in the bran if any, should be removed and the bran mixed with the sieved wheat flour.

Cooking of rice: Inthe natural state, rice is rich in vitamins of ‘B' Complex group, But these vitamins are present in outer layers of the grain.
During the process of milling, the germ of the grain which is highly nutritious, and most of the outer layer containing a higher concentration of the nutrients are removed.

Thus milled and polished rice though more attractive in appearance is poor in its is, therefore, advisable to consume hand-pounded and nutritive value.

It parboiled rice rather than consuming raw milled rice.

Parboiling of paddy is a well Known traditional practice.
It isa good means of protecting nutrients in rice from loss, During this process, ‘B' Group vitamins and other nutrients in the outer layers of rice go deeper into the grain and thus become resistant to subsequent loss.

Thus even the milling and polishing of parboiled rice will not entail much loss of nutrients.
Some of the processes involved in cooking of rice ere washing, soaking, cooking and sometimes draining the excess water after cooking, Since vitamins of 'B’ Group are water soluble, there is a risk of losing these vitam- ins in each ot these processes if proper care is not taken.

Washing of rice should not be excessive.

The rice should be first cleaned and then washed only 3-4 times.
If the rice is to be soaked before cooking, the water used for soaking should be just sufficient for cooking, The water in which the rice has been soaked should be utilised for cooking the rice.

In other words, to one part of rice add only 2 to 22 parts of water so that ail 148 water .is absorbed at the end of cooking.

If too much water is used, the excess water will have to be removed later on as ‘conjee’ which carries away quite a good amount of nutrients.
Rice should, therefore,be cooked in just enough water so that there is no extra water left after cooking.

If at all rice has been cooked in excess water, the excess water should not be thrown.

It should rather be given to children as a drink after adding some sugar or salt as desired.

This rice water could also be used in the preparation of dough, soups etc.
Proper handling and cooking of pulses: Like rice, pulses should also be subjected to minimum washing, soaking in just enough water required for cooking, and cooking in the water in which the pulses have been soaked.

Excess washing and throwing away of water in which the pulses have been soaked results in the toss of water soluble nutrients due to leaching, Sometimes soda-bi-carbonate is used to hasten the process of cooking of pulses particularly in the case of bengal gram, kabuli chana, rajmah, lobia etc.
Since soda-bi-carbonate destroys a good amount of vitamins of 'B' Com- plex Group, the practice of using soda-bi-carbonate should be discourged.

The whole pulses and legumes could, however, be soaked overnight so as to reduce the cooking time.

The use of pressure cooxer for cooking dal is also very useful since it reduces the time of cooking, In the absence of a pressure cooker, a weight can be kept on the lid of the vessel so as to create pressure inside the vessel.
Pressure cooking reduces the loss of nutrients by reducing the cooking time.

Sprouting of pulses brings about certain desirable changes in pulses, It increases the concentration of vitamins of 'B' Complex, converts a certain amount of carbohydrates in the pulses into Vitamin ‘C’, improves the bio-availability of Iron and other nutrients present in the pulses, improves the digestability etc.

Sprouting of pulses has been a traditional practice in India.

People use sprouted pulses on certain festivals.


It is therefore, desired that the practice of sprouting pulses is encouraged so that sprout- ing becomes a routine activity in the households rather an occasional activity.

For sprouting, whole pulses are soaked overnight in water.

Next morning the water is thrown away and the grains are tied in a muslin cloth and hanged.

The grains should be kept moist by sprinkling water on it frequently.
In order to have the maximum nutrients in these grains, itshould be consumed when the sprouts are half inch long.

Sprouted pulses require very little cooking, Some amount of heat treatment is always desirable because it destroys the anti-nutritional factor (trypsin inhibitor) present in the pulses.

Steaming the sprouted pulses for a minute or cooking for a few minutes (7 to 3 minutes) with a very little amount of water is sufficient, Sprouting takes more time in winter season than in summer.
In winter season it may take more than 48 hours while in summer it will be ready in just 24 hours.

Pulses like bengal gram, kabuli chana, green gram, biack gram, moth, cowpea etc.

can be sprouted and usea in preparing stuffed paranthas, potato tikias, raita, sandwiches, chutneys, pulao, salads etc.

When sprouted pulses are used in preparations which involve cooking, it is not necessary to cook them after sprouting.
Slight cooking as described above is necessary only when these are used as salads or in raitas and chutneys.

149 = to cook vegetables?

Much care has to be taken while processing and cooking vegetables since they are rich sources of minerals and vitamins and improper handling may result in loss of all these important nutrients.

Some of the important points for cooking of vegetables are as under: — Use vegetables as soon as they are brought, un'ess they are stored in a refrigerator or in a cool place.
Storing of fresh vegetables at room temperature or in hot climates results in destruction of vitamins.

Vegetables should be washed well before peeling.

Some vegetables may need a little washing after peeling also such as potatoes, colocasia etc.

since there is a lot of dirt on their skins.


While peeling vegetables, care must be taken to removeas thin askin as possibie since a large part of the vitamins and minerals in the vegetables lie just under the skin, In the case of vegetables like calabash cucumber (ghia), cucumber (kakri}, pumpkin etc.

if the skins are clean, peeling should be avoided.

While cutting the vegetables, care should be taken so that vegetables are not cut into too big or too small pieces.
Very big pieces take longer time for cooking thus resulting in loss of nutrients while very small pieces increase surface area thusincreasing the loss of minerals and vitamins due to leaching.

The cut vegetables should never be soaked in water.

If atall these have to be soaked in water to prevent browning, a minimum amount of water should be used which should later be utilised for cooking that vegetable.

Vegetables should be cooked in the minimum amount of water for as short a time as possible.
Pressure cooking is desirable since it reduces the time considerably.

Vegetable should be cooked in the vessel withits lid on so as to avoid the loss of nutrients due to oxidation.

Cooked vegetables (and any other food item) should be served soon after they are cooked.

Keeping them hot or re-heating the food results in loss of vitamins and flavour.

Vegetables like potatoes, colocasia, sweet potato etc.

should be boiled with their skin on.


Excess boiling should be avoided because if their skins are broken during boiling, there will be loss of nutrients due to leaching.

Leafy vegetables should be thoroughly washed before cutting, These should never be subjected to washing after cutting.

Green leafy tops of vegetables like raddish, knol-khol, cauliflower etc should not be thrown as they are rich sources of many nutrients.
These should be utilised in preparations like bhujia, dal, chapaties, paranthas etc.

or shauid be eaten in the form of salads Vegetables like tomatoes, cucumber, cabbage, raddish, carrots, onions etc.

should be eaten raw in the form of salad and should be included in the daily diet, Raw vegetables are more nutritious and are a good source of vitamin 'C’.

But care must be taken to wash them well in clean waterso as to remove all dirt and any harmful bacteria, if present.
beetroot, carrot, Certain tips about the fruits: Fruits are an important item of our diet and provide a lot of vitamins and minerals to our body.

itis necessary to consume some amount Of fruits to obtain these vitamins and minerals.

Nature has provided seasonal fruits in 150 allseasons which are-not only nutritious bul have the quality of meeting the special need of the season.

Fruits like Bananas, Guavas, Papayas, Mangoes etc.

are quite cheap during their season.

Banana is rich in its energy value.


Guava is a good source of Vitamin 'C’, Mangoes and Papayas are very important because they contain a substance called carotene which is con- verted to Vitamin ‘A’ in our body.

It is, therefore, desirable that some seasonal fruit is included in daily diet.

Like vegetables, it is advisable to avoid peeling in the case of fruits also if their skins are intact.
Fruits should be washed and cut just before eating because keeping the cut fruits at room temeprature results in the loss of vitamins.

In case juice has to be extracted, extraction must be done just before the consumption to avoid the toss of nutrients.

Cooking of eggs and flesh foods: Storing, handling and coeking of animal foods in a proper way is impor- tant to keep them free from the disease causing bacteria.

All such foods have to be stored inacool place.


It is advisable to use egas after cooking so that if any harmful bacteria are present they are destroyed during the process of cooking.

Meat, fish, eggs and other flesh foods are rich in protein and should, therefore, be cooked at low temperatures as protein gets toughened and denatured at high temperatures and becomes unavailabie to the body.

Storage of perishable foods: Foods can be classified into perishable and non-perishable.
Perishable foods are those which get spoiled easily such as milk, milk products, fresh food, fruits and vegetables.

Non-perishable foods include cereals, pulses and canned foods which can be stored for a longer period.

|i is important that all food that is produced is stored, processed and cooked without affecting its nutritive value.

Food becomes unfit for consumption if it is spoilt.
Spoilage can be due to (i) physical or chemical changes brought about in the food due to the action of micro organisms such as bacteria, mould and yeast; {ii) infestation with insects and worms; and (iil) toxins.

Food may become toxic due to contamination with metals like lead, copper etc.

Perishabie foods should be purchased in such quantities which do not last for more than a day unless there is a facility for cold storage.
Perishable foods have to be stored at cold temperatures so as to avoid the loss of nutrients.

For those who cannot afford to buy a refrigerator, ‘Janata Refrig- erator’ can be made at home by keeping an earthen pot in wetsand undera shed.

It requires avery small space and will keep fruits, vegetables, milk and even cooked tood fresh for several hours, Left-over foods can be boiled after every 4-5 hours to check the bacterial growth.
Fruits and vegetables can be dried, or processed and converted into squashes, syrups, morabbas jams, jellies, chutneys and pickles for use throughout the year.

Leafy veget- ables when available in plenty during season can be dried and stored in air-tight containers to enable its consumption throughout the year, As faras possible fruits and vegetables should be used fresh because there isa loss of vitamins particulary vitamin ‘C’ on storage.
Storage of non-perishable foods has been discussed in the chapter on storage of foodgrains.

151 S — e — — — _ — _ — _ — $ — $ — — — — — — Chapter 20 PRESERVATION OF FRUITS AND VEGETABLES A large number of fruits and vegetables are grown in our country and their production is often so high that every year we have substantial seasonal surplus.
Fruits and vegetables are perishable and thus they are available at very low price during the peak season, So, if these seasonal fruits and vegetables are preserved, it will extend the availability of fruits and vegeta- blés in all seasons and thus add to the nutrition of the people.

The tech- niques of preservation are simple and can be adopted at the domestic level after studying this chapter.
Various aspects of preservation of fruits and vegetables are discussed, under the following sub-heads: — Need for preserving fruits and vegetables.

— Factors responsible for spoilage of fruits and vegetables.

— Principles and methods of preservation of fruits and vegetables — Preparation of commonly used preserved products from fruits and vegetables.

— Dehydration and sun-drying of fruits and vegetables.

1.

Need for preserving fruits and vegetables.


Fruits and vegetables are nature's gift to the mankind and are an essential part of our diet, They not only meet the quantitative needs to a certain extent but also supply minerals and vitamins to our body thus improving our vitality.

Most of the fruits and vegetables are available in abundance at cheap rates in their respective seasons.

Due to their high moisture content, 152 they are highly perishable.
Being highly perishable they have to be pre- served and processed for future use.

It is only through preservation that we can extend the availability of fruits and vegetables for human consumption throughout the year The art of preservation has been Inherited by us through generations, Pickles and chutneys are made even in remote rural areas.

Itis necessary to preserve fruits and Vegetables firstly, because they are perishable commodi- ties and,secondly, because they are seasonal.
They begin to deteriorate shortly after harvest.

Deterioration of raw fruits and vegetables may result trom physical factors, action of enzymes, microbial action or combination ofall these agencies, Besides most of the fruits and vegetablesare seasonal and in certain cases the season is very short.

Since all the produce cannot be consumed during the season, a lot of spoilage could be prevented by preserving them.
Thus by the artof one not only Saves fruits and vegetables from getting spoiit but one aiso ensures a regular supply of vitamins and minerals for the family throughout the year.

preservation 2.

Factors responsible for spoilage of fruits and vegetables.

In order to understand the principles of preservation, it is necessary to know about the factors which spoil fruits and vegetables and how the same can de controlled.
The spoilage in fruits and vegetables occurs mainly due to the enzymatic activities in the fruits and vegetables and due to growth of micro-organisms, The enzymes are complex chemica substances which 816 present in all living organisms and tissues and control the essential metabolic processes.

It the enzymic actionin plants that we see the browning of cut surfaces of fruits and vegetables on expo- sure to air is only due to Enzymes can be permanently inactivated by extra heat.
Moderate heat increases their activity.

Thus heat processes such as bottling and canning will be effective in preserving foods.

Deep freezing temperatures (O°F & below) are effective in inhibiting the majority of enzymic actions.

Though enzymes are very essential but at a certain stage if their activity is not checked, they can spoil the fruits and vegetabies.

Micro-organisms: Micro-organisms are minute living organisms which are invisible to a naked eye but are present in all normal surroundings.
The important micro-organisms which are responsible for the spoilage of fruits arid vegetables are (a) Bacteria; (b) Yeast; and (c) Mould.

(a) Bacterial spoilage is sometimes difficult to detect because all the bacterial spoilt foods do not produce gas.

Usually the contents have a sour smell and mushy appearance.

They are capable of forming highly resistant cell or spore Bacteria: Most of the bacteria are destroyed near the boiling point.
Spore forming bacteria are also destroyed at 115°C for which pressure cooking is neces- sary.

Refrigeration slows down the rate of bacterial growth considerably and deep freezing inhibits it completely but neither of these cold treatments have any permanent effect and organisms subjected to them begin to multiply again as soon as they are returned to a suitable temperature.
The bacterial growth is also inhibited by the presence of high concen- trates of salt or sugar, Most of the bacteria including the spore forming ones are unabie to multiply in acid surroundings and are more easily 153 destroyed by heating.

It is for this reason that all low acid foods should be processed at higher temperatures and for longer time so as to ensure that the bacteria present have been destroyed.
The most important bacteria shigelia which can cause food poisoning are species of salmonella, Staphylococcus.

(b) Yeast: Yeasts grow well in acidic conditions and ferment sugar.

Most yeasts are non-pathogenic and are therefore not important medically.

Most of their species are readily destroyed by heat (140°F) fora few minutes and are inactivated by cold, deep freezing.

(c) Moulds: Majority of the moulds are sensitive to heat and are destroyed by heat treatment tor 30 minutes at 60°C.
Moulds are inactivated at deep freezing temperatures but the effect of cold is not permanent, After all these above mentioned spoilage agents are inactivated and destroyed, itis necessary to prevent further entry of these micro-organisms into the preserved products so as to prevent spoilage.

This can be ensured by using sterilised containers and air-sealing them by using paraffin wax after filling the contents.

3.
3.

Principles and methods of preservation of truits and vegetables: Different methods of preservation of fruits and vegetables are: + - ७ 1 ० ५ + ा ए ण 0 ७ ब ज Sun-drying and dehydration.

Heat processing, Preservation with salt.

Preservation with sugar.

Preservation with vinegar.

Deep freezing.

Chemical preservation.

1.


Sun-drying and dehydration: Any life including the micro-organisms can be active and survive only in the presence of moisture: If the moisturein fruits and vegetables is reduced to acertain level by sun-drying or dehydra- tion, the micro-organisms cannot grow to cause spoilage and the enzy- matic activities also cease, Thus removal of water from fruits and vegetables is called dehydration.
Large quantities of fruits and vegetables are dried in the sun in different parts of the world.

The modern method of dehydration i.e.

drying of fruits and vegetables under controlled conditions of tempera- ture and humidity is assuming increasing importance.

Since sun-drying and dehydration is a method which can be made use of by people even in remote rural areas, this aspect is discussed in detail separately.

2.
2.

Heat processing: Heating to an appropriate temperature in a suitable container to sterilize the contents before these are hermetically sealed is called heat processing.

Extreme heat completely inactivates the enzymes and destroyes all micro-organisms.

But if there is a leak, however minute it may be, it will allow air to be drawn into the container thereby allowing the introduction of many airborne micro-organisms, which on development, will render the contents unfit for consumption, 3.
Preservation with salt: If the salt is more than 15% in a product, itis preserved as in the case of mango and lemon pickles.

The preservative action it increases osmotic pressure resulting in the of sait is attributed to: (i) it dehydrates the food as weil as plasmolysis of the microbial cells; (ii) and tying up of the moisture by micro-organisms by ion-hydration.
draining out 154 Pickling is a process of preserving immature fruits and vegetables with added salt or brine (12-20%), In some pickies such as lemon, lime, raw- mango etc., the product does nat seem to undergo fermentation because of very high actidity4n other materials such as cucumbers the material under- goes lactic fermentation.

Salt in brine controls the growth of undesirable putrefactive organisms and permits the naturally present lactic acid bacte- ria to grow.
The level of acid developed ranges from 8% to 15% which supplements the preservative action of salt.

4.

Preservation with sugar: Ii the sugar is more than 68% ina product, itis preserved.Sugar absorbs water of the fruit with the result that tnelatteris not available for the growth of micro-organisms.

Sugar syrups containing more than 68% sugar have so little moisture available for micro-organisms that their propagation is inhibited and those already present also die gradually.
Thus sugar acts as a preserative through osmosis and not as a toxic agent for micro-organisms, 5 Preservation with vinegar: Vinegar acts as a preservative in pickles.

In order to ensure good results, the final percentage of acid (as acetic acid in the finished pickle) should not be less than 2.0%.

To avoid dilution of vinegar by water from their tissues, the vegetables are generally put in strong vinegar of about 10% acidity for several days before final packing.
This treatment besides other advantages also helps in expelling the gases present in the Inter-cellular spaces of vegetable tissues, Vinegar should not come in contact with iron as it leads to blackening of the pickle.

6.

Deep-treezing: The temperatures below freezing point retard the growth of micro-organisms and can inactivate the enzymes.

Various fruits, vegetables and their products are preserved with this principle.
When the temperature is around 15°F the growth of micro-organisms and the enzymatic activity is minimum.

At temperatures higher than this, their activity increases and they decompose the food.

Thus fruits and vegetables can be preserved for some time by keeping them at low temperatures (i.e.

refrigeration) 7.

Chemical preservation: The two common chemical preservatives permitted in different parts of the world are (i) benzoic acid (including benzoates) and (ii) sulphur dioxide (including sulphites).
These are allowed in India also (as per the Fruit Products Order), Sodium benzoate is a salt of benzoic acid and is used in preservation of fruits, juices and squashes.

Benzoic acid is the effective agent but since itis sparingly souble in water, its sodium salt, which is soluble in water is used.

It has been found that in the case of juices having PH 3.5-4.0 which is the range of most juices., 0.06-0.10% Sodium Benzoate is sufficient.

But in less acidic juices, at least 0.3% is necessary.
Sulphur dioxide : Potassium meta-bi-sulphite is used as a source of sulphur dioxide.

The dry chemical is easier to use than the liquid.

When itis added to the juice or squash, the potassium radical reacts with the acid of the juice, forming the corresponding potassium salt and the sulphur dioxide which is liberated forms the sulphuric acid with the water of the juice.
Accoring to the Indian Fruit Products Order, the maximum amount of Sulphur dioxide allowed in squashes and cordials is 350 ppm which corres- ponds to about 1 ounce of potasium meta-bi-sulphite per 100 Ib.

of the squash.

155 Preparation vegetables.

of commonly used perserved products of truits and 1.

Jams, Jellies & marmalades: Among preserved fruits, jams, jellies and marmalades form animportant class of products.
a) Jams: Jam is prepared by boiling the fruit pulp with sufficient quantity of sugar to a reasonably thick consistency, firm,enough to hold the fruit tissues in position.

Inits preparation about 45 kg of fruit should be used for every 55 kg.

of sugar.

It should contain not less than 68.5% soluble solids.

Ingredients: Fruit pulp Sugar Citricacid Pectin kg, + kg.

4gm.

4-6 gms.

or fruit containing pectin in the ratio of 3 parts of main fruit and one part of pectin rich fruit.

2 to 3 drops.
2 to 3 drops.

Essence (optional) Method of preparation: Select fully ripe fruit, wash itin running water.

Remove the peel, stones and core with the help of asharp knife.

Grate or cut the remaining portions of the iruitinto small pieces: Crush the pieces if they are soft.

If they are hard, boil them with a little water till they become soft and liberate sufficient pectin.

Find out the weight of the pulp.

For fruits which are not very sweet, add sugar 3/4 in weight to the quantity of pulp.
Addition of citric acid to the fruit deficient in acid is necessary because appropriate combination of pectin, sugar and acid is essential to give a set to the jam.

The fruit pulp and sugar are cooked till the end pointis reached, For testing the end point, place a drop or two of the jam ona dry plate and cool.

IFit sets, the jam is ready.

Citric acid is added a few minutes before the end pointis reached.

Generally the weight of the finished product is 1% times the weight of the sugar used.
Jam containing 68.5% soluble solids boils at 222.5°F.

at sea level, If the fruit does not contain sufficient pectin, cemmercial pectin or fruit rich in pectin (plum, apple etc.)

may be added, Pour the hot jam into the clean, dry and sterilized wide mouthed bottles, Add a thin layer of melted paraffin wax on the surface of the jam for sealing and put the lid on lightly.

Store in a cool and dry place b) Fruit jellies: In jelly making, pectin is the most essential component.
Pectin forms jellies when mixed with proper amount of sugar, acid and water, Ail these ingredients must be present ina particular ratio for making a good jelly.

Jelly is usually made from fruits which are rich in pectin ie apple, guava, plum etc.

The cee!

of these fruits is a good source of pectin and should not be removed.

156 Ingredients: Juice extract Sugar Citric acid Method of preparation: 1 kg.

1 kg.

5 gms.
1 kg.

5 gms.

One kg, of ripe fruit is washed, cut into thin slices and covered with an equal weight of water.

Add 2 gms.

of citric acid.

The mass Is heated for about 30 minutes to extract pectin.

The extract is strained through thin cloth.

The clean liquid is syphoned off and tested for pectin by alcohol test.

Alcohol test — Add 2 teaspoonful of methylated spirit to 1 teaspoonful of the juice extract.

Shake the solution gently and leave it undisturbed fora minute.
If the extractis rich in pectin, it will form asingle transparentiump of jelly like consistency butif the pectin is present only in moderate quantity, the ciot will be less firm and fragmented.

The presence of insufficient pectin will result in numerous small granular clots.

If the solution is found poor in pectin the fruitis boiled fora longer period to liberate the whole of the pectin presentin it.

Ifthe juice isrich in pectin, 1 kg.

of sugar per kg.

of juice extract is added.


If on the other hand it contains only a moderate quantity of pectin, 750 g. of sugar per kg.

of juice extract is added, Should the juice be poor in pectin, about % kg.

sugar is usually sufficient for each kg.

of juice extract.

After doing alcohol test, if the juice is found to be rich in pectin then add 1 kg.

sugar to every kg.

of juice extract, boil and cook the mixture stirring now and then.

Add 4 gms.
Add 4 gms.

of citric acid and cook the mixture till itsatisfies the ‘Sheet test’ or till the temperature reaches 220, 7°F or the jelly weighs about 1% times the weight of sugar used.

Sheet test — In this test some portion of thejelly is taken in a wooden spoon and cooled slightly.

Itis then allowed to drop.

If the jelly drops like asyrup, it requires further concentration, but if it falls in the form of a sheet, the end point has been reached.
Packing — Pour the finished jelly after removing the scum into clean, dry and serilized wide mouthed bottle.

Allow the jelly to cool.

Air seal the jar with melted paraffin wax.

Store in a cool, dry place.

c) Marmalades: in the preparation of marmalades, all the conditions necessary for jelly making are applicable.

A good marmalade can be made using any of the following combinations; i) ii) iii) iv) Malta and khatta 2:1 by weight.

Orange and khatta 2: 1 by weight.

Malta and galgal 2:7 by weight.


2 whole orange and one whole lemon.

Method of preparation: Select ripe fruits for any one of the 4 combinations mentioned above.

157 Wash them thoroughly and pee!

their outer skin carefully with a sharp knife.

Soak the peels in water and keep aside.

Cut the peeled fruits into transverse slices.

Put enough water to cover them and boil.

Onceit starts boiling, lower the heat and continue boiling for 35 minutes without disturbing the contents.
Take a teaspoonful of the clear extract and perform the pectin test on itas in the case of jelly.

Strain the hot extract through a muslin cloth and keep it aside for clarification.

While the extract is being clarified, prepare the pee!

shreds.

Remove the inside white portion of the peels by scrapping and cut into 3/4" to 1” long shreds.

To make-the shreds soft and less bitter, they are boiled for 10 minutes in 2 to 3 changes of water.
When the shreds are soft, drain the-water, Tie these shreds loosely in a muslin cloth and keep aside.

Add sugar according to the pectin present in the extract.

Boil and strain it again.

Place the bag of shreds in the extractand sugar mixture and cook the’ mixture till the ‘sheet test’ is confirmed.

Remove from fire.

Take out the bag of shreds, open it and spread on a plate for cooling for 2-3 minutes, Mix shreds with the hot marmalade and pour into sterilized bottles.
Seal the bottles with paraffin wax when it is cool, Store it in a cool dry place.

2.

Preserves and candies: The fruit or vegetable in pieces or whole when preserved by syrup of high sugar concentration are called “preserves” (murrabbas).

A fruit impreg- nated with sugar syrup and subsequently drained and dried is called a “candied fruit”.

Preserves: a} Preserves can be made froma variety of fruitsand vegetables like apples, amia, mango, pineapple, bel, carrot, petha etc.
ingredients: Fruit Sugar Water Citric acid 1 kg.

1% kg.

750 mi.

4-6 g. (4-1 tsp.)

Method of preparation: Selected fruits or vegetables are thoroughly washed and skin is removed (in certain fruits like amla, there is no need of peeling).

After washing and pesling, the fruitisboiled for 5-10 minutes, depending upon its softness, te stop the browning and for softening.

Fruit is then pricked uniformly and thoroughly with sharp needle or fork (stainless steel) for the sugar to penetrate into the fruit.
After pricking the fruit should be kept under water to avoid browning and exposure to air.

The prepared fruit is then cooked in sugar syrup.

The sugar syrup for 1 kg.

of fruit is prepared by mixing 1% kg- sugar with 750 mi.

water and 4-6 g. of citric acid.

The mixture is allowed to boil till sugar dissolves and is then strained through cloth.

In this syrup the prepared fruit is cooked for 10 minutes each for 2 days.
On the third day the syrup is to be boiled till the syrup gives 1-2 thread consistency when drawn between fingers.

158 b) Candy: Ingredients: Fruit Sugar Water 1 kg.

1% kg.

750 mi.

Method of preparation: The process for making candy is the same as that employed for preparing preserves with only this difference that the fruit is impregnated with a higher percentage of sugar and the total sugar content of the impregnated fruit is kept at 75% to prevent termentation.
The most suitable fruits used for making candy are pineapple, peel of orange, cherry and ginger, 3, Fruit syrups: When fruit juice is preserved with sugar, itis called "fruit syrup”.

The fruit syrup should have about 70% sugar, ingredients: Fruit juice Sugar Water Citric acid 1 litre.

3:6६.

750 mi.

18 gms.

Method of preparation: Extract the juice, pass it through a sieve and keep aside, Make sugarsyrup of three thread consistency by mixing sugar, water and citric acid.
To remove the dirt, pass the syrup througha muslin cloth and let it cool.

Mix the juice gradually with the cooled syrup.

Mixing the syrup and the coldjuice preserves the flavour of the product.

Finally fill the syrup in clean and sterilized bottles.

NOTE: i) For making pineapple syrup, it is essential to boil the juice separately.

Juice is to be then sieved and cooled.

ii) For making lemon syrup, there is no need to add citric acid.
Based on the above racipe, fruit syrup with any fruit juice can be prepared.

4.

Squashes: ingredients: Recipe-!

Juice - 17 litre Sugar- 2 kg.

Water- 1 litre Citric - 25-30 gms.

acid KMS - 3 gms.

Method of preparation: 1 litre Recipe-li Juice - Sugar - 14 kg.

Water - 750 ml.

Citric - 20-25 ams acid KMS - 2.5 gms.

Recipe-lll Juice.- 1 litre Sugar - 1% kg.

Water - 625 ml.

Citric - 20 gms.


acid KMS - 2 gms, For the preparation of squashes sugar, citric acid and water are mixed 159 together, heated, cooled and filtered through cloth.

The clean syrup is then mixed with the juice.

To improve flavour and colour an appropriate quantity of corresponding essence and colour may be added.

After mixing all the ingredients a chemical preservative like potassium meta-bi-sulphite dis- solved previously in a small quantity of water or juice is added.
The squash is then filled into washed and sterilized bottles, leaving about one inch head space.

The bottles are closed with lids and sealed with paraffin wax and stored in cool, dry place.

5.

Chutneys: Ingredients: Fruit pulp Sugar Onion Ginger Garlic Salt Garam masala Red chillie powder Glacial acetic acid Method of preparation: 1 kg.

1 kg.

100 gms.

30.gms, 10 gms.

30-34 gms: or as required.

5-10 gms.

or as required.

5-10 gms.

or as required.

1% tsp.

for 1 kg.

ready chutney.


Chutneys are made from fruits and vegetables like apples, peaches, plums, apricots, mangoes, cauliflower, carrots, tomatoes, raw papayas etc.

Onion, garlic, spices are added for flavour.

Vinegar, common salt and sugar are added to make them more palatable.
Vinegar serves as a preservative to some extent For preparing any chutney, fruit or vegetable is generally cut into pieces or grated or sliced into desired size and cooked along with grated onion, garlic and ginger till soft.

Then add sugarand ground spices like garam masala, red chillie powder and salt.

Sometimes vinegar extract of spices is used.

The spices should be added jus!


alittle before the final stage of boiling is reached because during prolonged boiling some of the essential oils of the spices and also vinegar will volatilise.

If in place of vinegar, glacial acetic acid is to be used, it should be added in the end after removing the mass from fire.

Sweet chutneys are usually cooked to the consistency of jam to avoid fermentation during storage.

Only dry and sterilized bottles should be used for filling chutneys.

6.
6.

Pickles: Preservation of fruits and vegetables in common salt (15-20%) or vinegar is called (the final percentage of acetic acid should not be less than 2) pickling.

Spices and oil may be added.

Spices are added to almost all pickles, theiramount depending upon the king of fruit or vegetable used and on the kind of flavour desired.

The spices cenerally used are carda- moms, bay leaves, chillies, cinnamon, clove.

cornanuer, ginger, mace, mustard, black pepper, cun in, turmeric.
garlic, mint, aniseed, fenugreek etc.

Gur or sugar is used for making sweet pickle.

For oil pickles, in North 160 India.,mustard vil preferred.

is commonly used and in South India, gingelly oil is Mixed Vegetable Pickle Ingredients Mixed Vegetable pieces (Lotus stem, jack fruit, yam, beans, green chillies, raw mango, lemon, karonda etc.)

1 kg.
1 kg.

Mustard Oil Onion Ginger Garlic Red Chillie powder Garam masala powder Salt Turmeric powder Glacial Acetic acid 300 6 1004 30g 10g 209 309 150 6 20g 6 m. /kg of finished product.

Method of preparation Wash vegetables thoroughly and cut into pieces.Blanch pieces of lotus stem, yam, jack fruit & beans in boiling water.

Tie these vegetables loosely in a muslin cloth and dip in boiling water for 3-4 minutes and remove).

Drain the water and dry in sunlight for sometime.

Heat the oil.
Heat the oil.

Fry grated onion, ginger and garlic.

Add all the masalas and then all the vegetables and remove from fire.

Add Glacial Acetic Acid and mix well, Cool and fill in clean and dry (dried in sun) jars.

Keep in a cool and dry place.

7.

Ketchups and sauces: Ketchups and sauces are prepared from the same ingredients as chut- neys, the difference being that the chutneys are thicker and contain spices, For preservation of both ketchup.and sauces, sodium benzoate at the rate of 1 to 1.5 g. per kg.
and glacial acetic acid at the rate of 5 mi.

per kg.

of the finished product is added, a) Tomato ketchup: Ingredients: Tomatoes Onion Ginger Garlic 1 kg, 100 gms.

30 gms.

10 gms.

For making -tomato pulp Spices, preservative & sugar for 1 kg.

pulp.

Sugar Garam masala Red chillie powder Salt Glacial acetic acid Sodium benzoate 100-150 gms.

5-10 gms.

5-10 gms.

20-30 gms.

or as required.

5 mi.

for 1 kg.

ready ketchup.

1 gm.

for 1 kg.

ready ketchup.


161 Method of preparation Tomato Ketchup is made by concentrating tomato juice or pulp without salt, sugar, vinegar, onion, ginger, garlic etc.

are seeds and skin.

Spices, added to the extent that it contains notless than 12% tomato-solids and 28% total solids.

Spices should be of good quality and should be added in proper proportions to give an agreeable flavour.
Spices (cloves, cinnamon, black- pepper, zeera, mace) are-tied loosely in a muslim cloth and placed in the tomato pulp during boiling .

Itis removed while bottling the product.

100-150 gms of sugar to 1 kg.

pulp gives good taste to the ketchup.

Only abouta third of the total amount of sugar required is added before cooking.

This helpsin intensifying and fixing the tomato colour.

The rest of the sugar is added a little before the ketchup is ready.

The percentage of sugar varies from 10 to 26.


Salt bleaches tomato colour and should be added in the end, The percen- tage of salt in ketchup varies from 1.3 to 3.5.

Use of yellow and greenish tomatoes make the ketchup brownish.

If glacial acetic acid is to be added in place of vinegar it should be added after removing the mass from fire,i.e., in the end, b) Mixed vegetable sauce: Ingredients: Vegetables (carrots, potatoes, pumpkin) Onion Ginger Garlic Tamarind Spices for 1 kg.

pulp.
pulp.

Sugar Sait Garam masala Red chillie powder Glacial acetic acid Sodium benzoate Method of preparation: 4 kq.

For making vegetable 100. gms, 30 gms.

| pulp.

10 ams.

100 gms.

200 gms.

36-40 gms.

or as required.

5-10 gms.

5-10 gms.

5 mil, for 1 kg.

ready sauce.

1 gm.

for 1kg.

ready sauce.

Mixed vegetables like pumpkin, carrots, potatoes, onion, ginger, garlic may be used for preparing vegetable pulp.

To make it sour tamarind pulp at the rate of 1% is added.
To make it more palatable sugar at the rate of 2% is added, The rest of the spices are added near the end.

Preservatives are added after removing the sauce from fire.

Dehydration and sun-drying of fruits and vegetables: Drying as a natural means of food preservation has been used for many foods — cereals, legumes, nuts and oilseeds — all of which are dried in large quantities after harvesting, usually under the sun.

Thesun drying of foodsin smatier quantities has been used at homes from time immemorial.
Products 162 prepared at home include various types of papads, dried vegetables, raw jackfruit, amchur, potato, banana, tapioca and sago wafers, mango and jackfruit pulp, spiced vegetable scrappings and chillies amla, supari, tamarind pulp, etc.

In sun drying, there is no possibility of temperature and humidity control.

The hottest days in summer are, therefore, selected tosun dry foods and food products.

This heips the foods to dry much faster, preventing them from getting spoiled due to “souring™.
Souring or turning acidic is usually due to growth of micro-organisms which act on the car- bonhydrates and release acid.

Removal of moisture quickly, which can be done by exposing the food to the sun on hot days, prevent growth of micro-organisms: The general steps taken for the home drying of foods are as follows: 1.

Various containers used for preparation, drying and storage are cleaned 2. thoroughly and dried by placing in the sun.
In making products prepared from flour of legumes, cereals such as papads, the flour is mixed with clean, sterile water, salt and other ingre- dients, rolled into thin layers and placed in the sun.

The preparation is unsually scheduled in the morning so that the products are dried in a day.

4.

3.

The fibrous parts of vegetables are removed and the vegetables cut according to the desired size.
|t is then “blanched” by dipping in boiling water for one to three minutes depending on the type and size of the vegetable.

It is cooled immediately in cold water and then spread into thin layers for drying in the sun, Certain vegetables like the potato retain their original colour without darkening if a sulphite dip is given to the vegetable before drying.

Fruits are also dried in the same way as vegetables except that the blanching is not carried out here.
Fish like Bombay duck (bombil), are cleaned and then dried in the sun.

The dried food is cooled and packed in insect proof and moisture proof containers like used biscuit tins, bottles, paraffin coated cloth bags, thick polythene bags, etc.

The tins and bottles are tightly closed with lids whereas the polythene bags are heat sealed.

Packing in small polythene bags would be advisable as the dried food could be used up quickly.

5.
5.

Dehydration of leafy vegetables: Leafy vegetables, since not available throughout the year at all places, can be dehydrated and used whenever required.

They can be easily dried and stored for use when fresh vegetables are not available.

Some of the leafy vegetables having varied use are chana leaves, methi leaves, coriander and mint leaves.
Dried methi leaves can be mixed with wheat flour while making dough, can be added to besan batter for making cheelas and used with potatoes for making bhujia, Mint and cori- ander can be reconstituted with a little water to be used in chutneys and raitas, Similarly other leafy vegetables can also be used after dehydration.
Leafy vegetables when available in abundance at low cost, may be pur- chased in bulk, These leaves should be cleaned, washed and spread on a clean sheet in the sun (under the shade) for drying, When completely dry, these can be powdered coarsely by rubbing with hands and stored in air-tight containers and used when fresh supply is not available.

163 Chapter 21 CONVEYING MESSAGES TO THE COMMUNITY Community need based programmes last longer.
Participation of the community in any programme is absolutely essential if impact is to be ever lasting.

Any message percolating through the commnuity elders and lead- ers is easily accpeted.

The message, therefore, has to be in unison with the traditions prevailing in the community.

Various aspects concerning the types of messages and how the same should be coveyed to the community are discussed js this chapter under the following sub-heads; — Need for nutrition education.
— Seeking the support of motivated people in the community who can help in nutrition education.

— Conveying health and nutrition messages.

— Some other useful hints about nutrition education.

— Organizing and taking part in meetings to consider nutrition matters.

Need for nutrition education: In other chapters, mention has been made of the need ta teach mothers how to feed infants and children properly, a child with diarrhoea or an infectious disease.
In other words, workers are expected to convey suitable messages to the people in the community in an appropriate manner so that the people adopt correct practices regarding feeding, immunization, clean- liness, etc.

This is called nutrition education.

It should be remembered that mothers are always keen to improve the health and nutrition of their children.

Unfortunately, many of them do not know how to do this.
Moreover, in poor communities there are other prob- lems such as an unhygienic (dirty) environment, lack of clean water, and shortages of food at some periods of the year.

Workers should understand these problems and should be able to teach mothers ways of overcoming them, in all cultures there are some beliefs and superstitions about food and food habits, especially with regard to the feeding of young children and feods during pregnancy and lactation.
The workers should know what beliefs and superstitions are common in her community.

It is her responsi- bility to convince people to give up wrong befiefs.

At the same time, she should teach people good heaith and nutrition practices, in all communities there will be individuals and groups who will require special nutrition and health care.

It is the duty of the worker to find out who these people are.

to convey appropriate nutrition messages to such persons.
She should then make an extra effort Seeking the support of motivated people in the community who can helpin nutrition education: A field level worker cannot improve the nutrition of a community by herself.

She needs all the help she can get.

In every community, there are 164 persons and groups who are helpful.
These persons may be either officials ofa particular branch of the government or informal leaders, e.g., the village head man, a teacher in the village primary school, a religious leader, or a traditional birth attendant or anyone respected in the community.

Voluntary agencies and women’s groups are often active and eager to help.

The worker should identify all the helpful individuals and groups (resource persons) in the community and establish good relationships with them before starting her work.
This is not only important for her nutritional tasks but also for all her activities.

When a worker makes an effort to change the dietary habits of the people through suitable messages, her task will be much easier if her messages are supported by the community resource persons.

If the village leader is convinced that a certain message is good for the community and he gives his approval and support, this will make the members of the community more receptive to that message.
Similarly, if the school teacher starts telling people about the benefits of good nutrition practices, the efforts of the worker will produce better results.

Before trying to convey nutrition messages, it would be wise for the worker to discuss these with some of the community resource persons.

Conveying health and nutrition messages: Nutrition education is notso easy as many people think.

This is because it is not easy to change people's eating habits.
If a worker tells a mother to feed her child in a certain way and the mother listens to her advice, it does not mean that the mother will actually start doing what the worker has told her.

To convince mothers to adopt better nutritional practices, the worker must first understand why people follow particular feeding practics.
Often the reasons for the feeding habits of the families will be linked to factors such as poverty, cost of foods, availability of foods, befiefs and superstitions about foods, and time available to the mother for preparaing food, Before starting nutrition education understand why people follow particular feed- ing practices.

Once the worker has understood the reasons for people's feeding habits, she can start nutrition education.
The following simple rules will help in getting good results: Person-to-person discussions: — Talking with one mother at a time (person-to-person approach) is an effective way of conveying a message.
— Talking to a mother, when her child is not well and she needs help, is a good time to convey messages, — Not more than one or two messages af a time should be discussed, — The messages being conveyed should not go against the mother’s cul- ture or religion, — While conveying a new message, it is always useful to mention some common beliefs and practices prevailing in the community that should be encouraged.
For example, in many cultures, a religious-cum-social function is held to introduce solid foods to a six-month-old baby to initiate the adult-type of diet.

— Do not give any message that mothers cannot follow for other reasons, (poverty, religion, illiteracy, lack of knowledge, etc.)

165 Group education: Workers will get many opportunities to talk to a number of mothers together.

On such occasions they should try to convey nutrition and health messages to them.
In doing so, they can use teaching aids such as posters, flip-charts, and photographs.

Sometimes, slides and even films may prove useful.

A child who has recovered from malnutrition as a result of a good diet composed of cheap locally available foods can be a very convincing exam- ple to use in such group discussions, especially if the mother of the child also explains how the diet was changed and why and what improvements she noticed.
"Before and after” pictures of local children will also be useful in starting discussions.

Similarly, growth charts can also be used.

in countries that have nutrition rehabilitation centres, tne mothers of mai- nourished children are Sometimes asked to help in preparing food for children at the centre.

They may also be asked 10 1817 in feeding the children.

This is a good practice because such mothers become convinced about good nutrition practices once they see their own children healthy again.
Workers can ask these mothers to help in group discussions.

Some other useful hints about nutrition education : Catch the attention and interest of the mothers: lf a woman has asked a question about her child, you have a good opportunity because she will be interested in your reply.

Look forsometning about which you can compliment her.

For instance.is herhometidy, is her child bathed and clean, and is she breast-feeding her child?
It may also be worthwhile to see if the growth chart of her child shows regular weighing and completed immunizations.

The mother gets the feeling that personal interest is being taken in her child and family and she will listen carefully to what you have to say.

The message should apply to the mother's situation and to her hopes and desires.

If her child has fever, the first message should be about how to reduce the temperature.
Only afterwards will she listen to what you say about feeding children who are ill.

Motivation and acceptability of a message depend on the immediate needs and desires of a mother.

The message should be simple.

Try to put across only one or two ideas at a time, The ideas should be closely connected to something the mother already knows: The message should be heard, seen and understood.

Speak clearly and use simple words.

Whenever possibile, use pictures etc., to show what you are talking about.
This is important with different types of foods.

Mothers will understand the message more easily / simple examples are given Participation: It is easy to forget what has been said or seen, but doing something helps to remember it.

What is even better is to show someone else how to do something.
Ifa childis not growing well and a mother is told to give him extra food each day, she may not remember it, If the worker encourages her and helps her to get started, the mother may give the child the extra meals regularly, As the child's growth improves the mother will feel proud and happy at what she has achieved.

She will remember the impor 166 tance of more meals for small children.
If the child was simply sent off somewhere for an extra meal twice a day promoted by a feeding programme, the mother will never really know about the importance of extra meals.

A local proverb or a joke can make it easy to remember a message.

“A smail seed, if properly nourished, grows into a mighty tree" It isobviously necessary to use a proverb correctly.

It is important not to offend people.


Understanding and judgement are necessary when making jokes in another language or in a Culture different from one's own, Repetition reinforces a message.

After telling a mother something, itis useful to ask her to repeat the message and explain itin her own words.

This will help her to remember it, The test of her understanding will be to see if she carries out the instructions in her own home.
A friendly and respectful relationship is a great help when teaching or learning.

A welcoming smile and a helpful deed are a good beginnina for exchanging information, An arrogant attitude will create barriers to learning.

Organising and taking part in meetings to consider nutrition matters : Discuss nutrition problems in community gatherings.

Every culture has some form of gathering where people discuss matters of common interest.

Sometimes all important decisions are made at such meetings.
There may be different meetings for different groups, for example, young farmers, mothers, community leaders, and so on.

Various aspects of nutrition could be discussed at these meetings.

If there is no suitable group or meeting to discuss nutrition and heaith, the field worker may have to start one.

Every meeting should have a difinite objective, and for each objective a list of topics should be prepared.

Both the objective and topics should be known to the people attending the meeting.
The field level worker should prepare teaching methods and aids suited to the topics that will be dis- cussed at the meeting, because it provides an important learning opportun- ity.

She should collect all the materials which can illustrate the topics being considered: for instance local foods, weighing scales, and growth charts, She should make sure that the leaders of the community are invited.
This means not only the official leaders, but also those who are looked upon for guidance by others in the area.

|i possible, she should have the meeting led by someone who will understand the social, economic and health issues associated with nutrition problems, someone who is respected by others and not afraid of change.

The meetings should follow the local pattern, but an effort should be made to keep them informal.

The worker should be prepared to take active part.


She can asx questions ano make comments tnat will help the meeting going in the right direction.

The purpose of such a meeting is to keep nutrition and health issues in people's minds.

It is an opportunity to inform them aocut other factors that affect health.

The most important purpose: nowever, is to stimulate the people in the community tobe active and do something about their nutritional problems.
What is needed is personal and community commitment to make changes that will improve the nutrition and health of the high-risk groups.

This is notan easy task, and very quick results should not be expecied, Patience and persistence will be necessary 167 9 1 1 0 1 2 1 8 | , .

s m g 0 0 1 r e p e r a n e v i g s e u l a v e h t l l A ) .
g m { C n i m a t i V ) .

g m ( n i c a i N - o b i R n i v a l f ) .

g m ( - a i h T e n i m ) , g m ( ) - g u ( ) .

g m ( ) .

g m ( e n e t o r a C n o r l m u i c l a C ) 1 ३ ० ( y g r e n E t a F ) .

g ( ) .

g ( n i e t o r P f f u t s d o o f f o e m a N ; 5 , o N ooooococco ooc°coersd 3 2 4 .

5 1 .

3 8 .

1 1 .

1 1 .

1 9 .

1 5 .

5 9 .

2 0 .

2 3 .

1 1 .

2 5 .

1 9 .

2 5 2 .

0 0 2 .

0 3 1 .

0 0 1 .

0 6 1 .

0 9 1 .

0 6 0 .

0 7 1 .

0 5 1 .

0 0 2 .

0 0 2 .

0 7 2 .

0 0 2 .


0 7 1 .

0 3 3 .

0 7 4 .

0 7 3 .

0 2 4 .

0 8 9 .

0 2 4 .

0 6 0 .

0 5 4 .

0 0 3 .

0 2 4 .

0 1 5 .

0 7 4 .

0 2 4 .

0 9 3 .

0 FRoIUos 0 1 2 3 1 0 2 1 0 .

5 0 , 3 8 .

5 0 .

2 8 .

3 4 .

6 1 .

3 3 4 1 .

9 9 .

5 3 .

7 4 .

8 4 ~ ~ 2 .

 .

5 3 .

1 9 .

1 6 .

3 6 .

7 3 .

1 5 .

0 5 .

1 3 .

5 4 .

1 0 .

1 3 .

1 5 .

0 6 .


0 6 .

1 1 5 .

1 1 4 .

0 1 1 , 1 1 6 .

3 1 3 .

7 8 .

6 8 1 1 a W 0 .

4 2 4 .

4 2 0 .

4 2 0 .

2 2 2 .

 , w a r , e c i R ) e l o h w ( t a e h W y r d e z i a M l a e m t a O i g a R “NO TM OP ९० s e m u g e l d n a s e s l u P ) e l o h w ( m a r g .
l a g n e B ) e l o h w ( S868 | So 898 &8 8 8 8 = 1 1 6 .

2 ै ज ् च ् ब 5 .

1 4 .

3 9 .

2 2 .

3 6 .

0 6 .

0 4 .

0 9 .

1 8 .

0 0 .

1 9 .

0 5 .

0 4 .

5 ) .

g m ( C n i m a t i V ) .

9 7 1 n i c a i N 0 1 - e b i R n i v a l f ) - 9 ए ( , 0 2 .

0 9 0 , 0 9 1 .

0 9 1 .

0 9 3 .

0 4 1 .

0 0 1 .

0 9 0 .

0 5 4 .

0 6 0 .

9 6 2 .

0 3 0 .

0 6 2 .

0 7 5 .


0 - a i h T e n i m ) .

g m i 5 4 .

0 5 4 , 0 7 4 .

9 5 4 .

0 3 7 .

0 1 0 .

0 9 0 .

0 6 0 .

0 6 0 .

0 5 0 .

0 5 0 .

0 3 0 .

0 1 0 .

0 3 0 .

0 1 3 .

0 ) .

g u ( ) .

g m ( } .

g m ( e n e t o r a C n a r f m u i c l a C ) , l a C ( y g r e n E t a F ) 9 ( ) 9 ( n i e t o r P f f u t s d o o f f o e m a N a .

o N 8 0 7 2 9 3 2 3 1 4 6 5 , 3 0 4 7 , 1 8 7 9 0 2 1 8 1 9 , 8 0 0 0 , 2 1 0 2 6 , 1 2 2 6 , 2 0 8 3 , 4 0 8 5 , 5 6 9 3 , 9 8 .

4 5 .
4 5 .

9 1 .

5 8 .

5 8 .

5 5 .

1 1 9 .

2 2 2 .

4 8 .

3 2 8 .

0 0 .

0 4 7 .

8 3 5 .

8 1 6 .

5 1 3 .

6 1 5 .

2 1 9 .

0 1 4 .

 285 2 7 TPSAIRG 7 7 7 .

0 1 .

1 1 .

1 3 .

1 7 .

1 5 .

9 1 3 .

0 4 .

0 4 .

1 1 .

0 3 .

1 0 .

2 6 .

0 6 .

0 6 .

0 4 .

0 7 .

0 5 .

1 o 1 .

5 2 6 .

3 2 7 , 9 1 3 .

2 3 2 2 2 .

3 4 0 .

3 7 .

3 0 .

7 8 .

1 9 : 5 8 .

6 3 .

3 8 4 0 .


4 1 .

5 0 .

2 0 .
, ) y t e i r a v k c a l B ( 169 1 1 2 1 0 1 9 ) .
g m ( C n i m a t i V } .

g m ( n i c a i N - o b i R n i v a l f ) .

g m ( - a i h T e n i m ) , g m { e n e t o r a C n o r l ) .

9 £ ( } .

a m ( ) .

g m { m u i c l a C ) .

l a C ( y g r e n E t a F ) .

g i ) .

g ( n i e t o r P f f u t s d o o f f o e m a N , 8 o N 3 0 0 1 1 1 7 1 1 2 4 2 ag 1 8 8 0 2 1 2 1 6 5 7 0 2 1 4 .

0 4 .

0 6 .

0 .

4 .

0 2 .

1 4 .

1 7 .

0 3 .

0 5 .

0 7 .

0 4 .

0 5 .

0 2 .

0 9 .

0 8 .

0 0 .

1 2 .

0 2 .

0 9 0 .

0 2 0 .

0 3 0 .

0 1 0 .

0 1 0 , 0 3 0 .


0 4 0 .

0 0 1 .

0 4 0 .

0 7 0 .

0 1 0 .

0 9 0 .

0 1 0 .

0 1 1 .

0 0 1 .

0 7 0 .

0 4 0 .

0 4 0 .

0 9 0 .

0 0 1 .

0 8 0 .

0 0 1 .

0 2 0 .

0 8 0 .

0 5 0 .

0 4 0 .

0 6 0 .

0 6 0 , 0 7 0 .

0 3 0 .

0 4 0 .

0 8 0 .

0 3 0 .

0 5 0 : 0 o 0 6 2 6 2 1 4 7 0 3 0 1 4 0 .

1 2 .

2 7 .

1 4 .

0 7 .

0 7 .

0 0 .

1 8 .

0 9 .

0 4 , 0 6 .

0 8 .

0 8 .

1 7 .

0 9 .

0 4 .

1 5 .

1 s w 5 4 3 .


5 = 325 7 4 0 1 0 2 6 4 0 5 0 3 0 5 0 3 0 2 0 2 8 1 3 3 0 1 0 3 - S35 .

0 2 .

0 1 , 0 1 .

0 1 , 0 1 .

0 1 .

0 3 .

0 2 .

0 2 .

0 1 .

0 1 .

0 2 .

0 1 .

0 3 .

0 1 .

0 4 .

0 1 .

0 1 .

0 7 .

1 9 .

0 0 .

3 7 .

1 2 .

1 6 .

1 5 .

0 2 .

1 7 .

0 5 .

0 2 .

1 4 0 6 .

1 2 .

0 4 .

1 5 .

4 6 .
2 4 , 0 5 : , n o i n O o t a t o P e l b a t , , 170 0 1 1 2 1 1 ) g m ( C n i m a t i V ) g m ( n i c a i N - o b i R n i v a l f ) , g m ( - a i h T e n i m } .
g m { e n e t o r a C n a r I ) .

g u } .

g m ( ) .

g m ( m u i c l a C ) , l a C ( y g r e n E t a F ) .

4 ( 1 .

9 ( n i e t o r P l l u t s d o o f f o a m a N , 5 o N 4 2 4 1 3 1 2 1 8 1 1 3 oonroc 0 5 4 1 1 7 .

0 3 .

0 2 .

0 6 .

0 2 .

0 1 .

0 5 .

0 8 .

0 5 .

0 3 .

0 4 .

9 0 4 .

4 2 .

1 0 .

3 0 .

4 9 .

9 1 5 .

9 9 .

0 6 0 .

0 6 0 .

0 4 0 .

0 0 1 .

0 1 0 .

0 1 0 .

0 6 0 .

0 1 0 .

0 4 0 .

0 8 0 .

0 1 0 .

0 7 5 .

0 9 1 .

0 1 0 .

0 3 1 .

0 6 2 .

0 3 4 .

0 9 3 .


0 0 1 .

8 8 0 .

9 5 0 .

0 7 0 .

0 4 0 , 0 1 0 .

0 5 0 .

9 5 2 .

0 6 0 .

0 4 0 .

0 7 0 .

0 4 2 .

0 3 6 .

0 8 0 .

0 0 9 .

0 5 6 .

0 7 8 1 2 3 1 7 7 .

1 7 1 5 .

1 4 5 9 .

0 7 .

1 5 .

1 7 .

0 9 .

0 8 1 0 1 2 SRRSIRAG 2 s 1 2 3 2 5 4 7 .

2 8 .

2 9 .

7 1 है 88 88 5 5 6 6 9 5 2 6 6 7 6 5 1 4 5 3 9 .

0 9 1 .

0 5 4 3 5 7 1 3 : 2 2 .

1 0 6 1 6 4 2 7 .

0 1 .

0 3 .

0 2 .

0 1 .

0 2 , 0 3 .

9 1 , 0 1 0 2 .

0 1 .

0 9 .

8 5 9 .

6 4 3 .


2 6 7 .

0 4 7 .

9 3 2 .

6 6 .

0 8 .

3 7 1 6 .

2 9 .

1 7 0 7 0 0 .

2 2 .

7 4 1 4 .

1 9 .

1 8 .

0 2 2 .

1 2 8 .

6 3 .

5 2 0 .

0 2 9 .

2 9 .
5 1 r e d n e t , s n a e b d l e i F s n a e b h c n e r F ) l a h t a K ( r e d n e t , k c a J s r e g n i f s e i d a L n e e r g , o g n a M n e e r g , a y a p a P r a w r a P s a e P n i k p m u P n e e r g , ) y r d ( , s e i l l i h C , s e i l l i h C 8 6 9 6 171 1 1 2 1 0 1 8 ) .
g m ( C n i m a t i V ) .

g m ( n i c a i N - o b i R n i v a l f ) .

g m ( - a i h T e n i m ) .

g m ( ) .

9 & ( e n e t o r a C n o r i ) .

g m ( ) .

g m ( m u i c i a C ) , l a C ( y g r e n E t a F ) .

9 ( ) 0 9 ( n i e t o r P f f u t s d o o f f o e m a N ooo ९0% | o 1 1 .

1 4 .

0 6 .

0 4 .

1 3 .

2 2 .

0 6 .

0 5 .

0 3 .

0 4 .

0 9 .

0 3 .

0 4 0 2 , 0 * 1 .

0 4 .

0 3 1 .

0 5 3 .

0 9 2 .

0 3 2 .

0 3 0 .

0 4 1 .

0 1 0 .

0 3 1 .

0 8 0 .

0 8 0 .

0 4 1 .

0 2 0 .

0 2 6 .


0 3 0 .

0 1 0 .

0 ° 1 0 .

0 6 0 .

0 8 0 .

0 2 2 , 0 4 3 .

0 6 0 .

0 6 0 .

0 9 0 .

0 3 0 .

0 3 0 .

0 4 0 .

0 5 0 .

0 8 0 .

0 3 0 .

0 1 0 .

0 2 1 .

0 3 0 .

0 3 0 .

0 " 2 0 , 0 2 0 .

0 2481 8 7 og oS 0 6 1 , 2 9 .

4 9 .

7 1 1 .

4 1 3 .

1 6 .

2 8 .

6 1 8 .

4 1 2 .

1 0 .

1 2 .

2 9 .

0 3 .

1 5 .

8 3 .

7 2 , 0 4 1 2 .

1 3 .

2 7 .


 .

8 1 , 6 1 8 .

5 1 .

0 9 .

0 8 .

6 1 .

5 1 .

6 5 0 3 0 3 .

0 5 , 0 5 .

0 4 .

0 1 .

0 3 .

0 3 .

0 9 .

0 2 .

0 2 .

5 1 .

4 1 2 .

6 2 3 .

6 3 .

2 3 .

6 5 .

1 1 5 ढ ब 5 .

0 0 .

1 2 .

1 1 .

1 7 2 5 .

2 0 .

1 9 .

0 7 .

0 0 .


1 1 1 s d e e s y r d , , r e g n i G y r d , r e p p e P c i r e m r u T h s e r f , s t o c i r p A d e r e p i r , s e i r r e h C , a n a n a B k c a l b , s t n a r r u C d e i r d , s e t a D s ' h s r a M ( t i u r f e p a r G ) s s e l d e e s y r t n u o c t i u r f , .

5 .
5 .

o N 0 7 1 7 2 7 3 7 4 7 5 7 6 7 8 7 9 7 S83 8858 1 8 172 1 1 0 1 2 1 9 ) .

g m ( C n i m a t i V ) .

g m ( n i c a i N - o b i R n i v a l f ) .

g m ( - a i h T e n i m ) , g m ( ) , 9 » ( ) .

g m ( ) , q a m ( ) .

l a C ( e n e t o r a C 1 7 0 1 m u i c l a C y g r e n E t a F ) .

g ( ) 9 ( n i e t o r P f f u t s d o o f f o e m a N > S , o N "mee 3 6 1 9 3 6 0 5 7 2 0 1 .

0 9 .

0 1 .

0 2 .

0 5 .

0 2 .

0 1 .

0 3 .

0 2 .

0 4 .

9 8 .

2 6 .

2 8 .

4 6 .

2 9 0 .

0 4 0 , 0 5 2 .


0 3 0 .

0 3 0 .

0 2 1 .

0 1 .

0 3 0 .

0 6 0 .

0 2 0 .

0 8 0 .

0 2 0 .

0 4 0 .

0 2 0 .

0 6 0 .

0 0 2 .

0 4 0 .

0 2 6 .

0 2 1 .

0 3 4 7 , 2 4 0 1 , 1 8 2 8 1 7 9 6 6 1 1 5 3 3 .

0 7 .

0 3 .

1 9 7 3 .

0 5 .

0 4 .

2 5 .

0 2 .

1 6 .

0 0 .

2 4 .

0 3 .

9 1 .

2 1 .

9 1 9 .

0 3 .

5 5 .

2 4 1 1 1 6 2 7 1 5 1 0 2 0 1 8 2 9 2 4 0 8 1 6 1 9 8 3 , 1 9 5 RESSSESISAR 3 9 2 9 1 1 3 7 2 7 8 9 8 1 0 1 0 .

1 3 .

0 4 .

0 2 .

0 2 .

0 1 .

0 3 .


0 2 .

0 1 .

0 5 .

0 1 .

1 2 .

0 0 .

4 2 .

3 4 .

9 1 9 .

0 3 .

1 0 .

1 9 .

1 5 .

1 8 .

0 6 .

0 2 .

0 7 0 6 .

0 2 .

1 6 .

0 4 .

0 7 .

0 7 .

0 9 .

0 7 1 6 3 .

0 2 8 .

1 2 5 .

0 2 0 .

7 1 1 .

9 1 0 .

1 2 s d o o f a e s r e h t o d n a s e h s i F d e i r d , k c u d y a b m o B ° 1 0 1 n a i d n I , g n i r r e H r e t s b o L a s l i H e t i h w , s t e r f m o P e n i d r a S n w a r P 2 6 1 .
3 0 1 4 0 1 5 0 1 6 0 1 7 0 1 t e e w s , e m i L i b m a s u M r e t a w , n o l e M e p i r o g f a M e p i r , .

s r a e P a t o p a S m u i P 9 8 .

0 9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 9 9 9 e p i r , o t a m o T 0 0 1 173 2 1 ONS Re ४७2 wv 1 4 6 1 .

9 } .

g m { ( c C n i m a t i V ) .

g m ( n i c a i N 4 0 .

0 0 4 .

0 5 1 .

0 0 1 .

0 8 1 0 1 5 0 1 .

0 9 1 .

0 4 0 .

0 2 0 , 0 6 1 , 0 4 6 .

1 6 3 .

1 4 0 .


0 5 0 , 0 5 0 , 0 2 0 , 0 5 0 , 6 _ 5 4 .

0 1 3 .

0 8 4 4 5 5 5 1 4 1 3 0 0 0 2 4 8 .

0 1 .

2 2 .

0 2 .

0 3 .

0 न 2 .

0 1 .

0 4 .

1 6 .

0 0 1 2 1 0 1 2 0 2 1 0 7 1 9 4 1 4 1 1 3 7 1 8 1 1 7 1 1 res?

7 5 0 7 3 , 1 7 5 3 0 1 - a p i R n i v a l f ) .

g m i 9 - a i h T e n i m ) 9 0 ( 8 7 A n i m a t i V n o r I ) .

g u l o n i t e R ( ) , g m { ) , g m ( m u i c l a C ) .

l a C ( y g r e n E t a F 1 .

9 ( ) .


g ( n i e t o r P f f u t s d o o f f o e m a N .

S .

o N 6 .

2 3 .

3 1 6 .

3 8 .

8 1 .

4 5 .

4 4 .

3 0 .

4 W w W 1 .

0 7 .

6 2 0 .

1 8 0 .

0 0 1 6 .

0 0 1 0 .

0 0 1 6 .

2 2 3 .

3 1 4 .

1 2 3 .

4 2 .

3 3 .

3 1 1 1 .

3 8 .

0 0 .

8 3 8 .


 ) k l i m s ' w o C ( n a m u h , ' o t a f f u b s ' w o c , k l i M , k i i M s ' t a o g .
k l i M 1 1 1 2 1 1 3 1 1 4 1 1 5 1 1 6 1 1 7 1 1 ) k l i m s ' w o C ( r e d w o p r e d w o p k l i m e l o h W 8 1 1 ) k l i m s ' w o C ( — ) d e i f i t r o f { ) o l a f f u b ( ) w o c ( r e t t u B e e h G e e h G 9 1 1 0 2 1 1 2 1 2 2 1 174 + o .

5 8 9 1 .

R M C I , N I N , s d o o F n a i d n i f o e u l a v e v i t i r t u N : e c r u o S 5 3 1 2 8 2 6 , 1 6 8 3 9 1 3 0 4 3 0 4 7 2 .

0 3 .

0 0 .

1 9 .
0 3 .

0 0 .

1 9 .

0 4 s t f u t s - ( y r e g g a J 4 2 1 .

5 2 1 6 2 1 ) m l a p 2 1 1 1 ) .

q a m { C n i m a t i V } .

g m ( n i c a i N 9 1 - o b i R n i v a l f ) : g m ( e n i m ) g m ( ) .

g u { e n e t o r a C n o r I ) .

g m i 6 } .

g m ( m u i c l a C ) .

l a C ( y a o r e n E t a F ) 9 ( ) 9 ( n i e t o r P f f u t s d o o f f o e m a N S .

o N !
o N !

i o g n i k o o C 3 2 1 , t u n d n u o r g ( , d r a t s u m ) .

c t e , y l l e g n i g t u n o c o c 175 - u c i N e i n i t l u c a d / g n i - o b i R n i v a l f - a i h T n i m d / g m d / g m - o r a c - B e n e t - i t e R l o n d / g m d / g m d / g .

A .

t i V n o r I - ) 9 8 9 1 ( + 3 .

0 + 2 , 0 + .

.

3 .

0 + 2 .

0 + 0 0 8 3 2 a 2 .


0 + 2 .

0 + 3 8 3 4 .

1 6 .

1 9 .

1 1 .

1 3 .

1 5 .

1 2 , 1 .

4 1 6 .

1 9 0 1 .

1 2 .

1 0 0 4 2 = 0 0 4 2 8 2 0 0 4 g k !

g 0 7 g / k g u 0 5 6 e k / g u S O 8 2 / 8 0 0 6 g k / g y S S g k i g i p O S 8 1 1 3 1 5 1 3 1 6 1 4 1 7 1 4 [ 7 .

0 0 1 2 , 1 3 .

1 2 .

1 5 .

1 2 .

1 6 .

1 2 .

1 6 .

0 9 0 0 .

1 1 .

1 0 .

1 2 .

1 0 .

1 3 .

1 0 .


1 0 0 4 2 0 0 4 2 ) 0 0 4 2 ess डे ह / l a e K 0 6 0 5 5 1 + 5 2 + 8 1 + 5 2 4 2 5 7 8 2 0 0 8 3 5 7 8 1 5 2 2 2 5 2 9 2 0 0 3 + 0 5 5 + 0 0 4 + e k / 5 0 2 g k / 5 6 .
1 g k / ‘ .

8 2 .

2 1 0 .

9 1 9 .

6 2 4 .

5 3 5 .

1 3 8 , 7 4 7 .

6 4 1 .

7 5 9 .


9 4 s h t n o m 2 1 - 6 s h t n o m 4 - 0 n o i t a t c a L s h t n o m 2 1 - 6 s h t n o m 6 - 0 s r a e y 3 - 1 s r a e y s r a e y 6 - 4 9 - 7 s r a e y s r a e y 2 1 - 0 1 2 1 - 0 1 s r a e y s r a e y 5 1 - 3 1 5 1 - 3 1 .
s r a e y s r a e y 8 1 - 6 1 8 1 - 176 i h t e D w e N , R M C I , = e c r u o S I I E R U X E N N A , d t n o C .

i h l e D w e N , R M C I , - .

e e r u o S .
e e r u o S .

t i V 2 1 - 8 d l e p 5 .

1 2 .

0 0 .

1 - 2 .

0 0 .

1 - 2 .

0 0 .

1 - 2 .

0 a c i l o F d s e p 0 0 1 0 0 1 0 1 - 2 0 0 0 1 r o c s A c i b d i c a d f e m o - i r y P n i x o d d / g m s r a l u c i t r a P p u o r G 0 4 0 4 0 4 0 4 0 4 0 .

2 0 .

2 5 : 2 5 : 2 1 .

0 4 0 9 0 6 .

1 0 .


 - 6 s h t n o m 6 - 0 n o i t a t c a L s h t n o m s h t n o m 6 - 0 2 1 - 6 s r a e y s r a e y s r a e y 3 - 1 6 - 4 9 - 7 s r a e y 2 1 - 0 1 s r a e y 2 1 - 0 1 s r a e y s r a e y 5 1 - 3 1 5 1 - 3 1 s r a e y s r a e y 8 1 - 6 1 8 1 .
- 0 1 s r a e y s y o B 2 1 - - 4 s r a e y 3 - - - - - n o n 178 ) l a e K ( s e i r o l a C ै ह n o i t a t c a l g n i r u D ) l a c K ( .
६ 0 6 .

६ 0 3 .

4 0 0 1 .

g 0 1 .

q 0 1 a a 8 1 1 2 5 3 8 ू त 0 4 3 9 2 .

0 .

6 .

g 5 9 3 5 1 0 0 1 ा ग g O = < , i h t e D w e N , .

R .

M .

C .
R .

M .

C .

I , — : + , .

1 .

2 .

4 .

2 ) g 0 3 - 0 2 ( s e s l u p f o % 0 5 ) g 0 6 - 0 4 ( s e s l u p f o % 0 0 1 + ANNEXURE - IV SOME DO’S AND DON'TS GENERAL , Include a variety of foodstuffs in your daily diet.
A mixed diet is more nutritious.

.

Include pulses in some form or the other in each meal.

The cereal-pulse N n combination provides superior quality of protein.

.

Take green leafy vegetables daily.

Take seascnal fruits like mangoes, guavas, bananas etc if possible.

.

Consume some amount of milk daily if possible.

.

Use mixed cereals in your diet.

.

Use unpolished/parboiled rice.

Include some raw vegetables in your diet like radish, carrot, onion etc, Use sprouted pulses more often.

.
.

Mix bengal gram-flour with wheat fiour in the ratio of 1:3 for making w a H M I M O C 11, 12.

13.

14.

15 chapatiles.

Mix leafy vegetables with flour for making chapaties, dals, curd ete.

Add just enough water for cooking.

Wash vegetables before cutting.

Cook vegetables in a covered pan.

Wash rice and putses before soaking: Use the same water in which tne grain is soaked for cooking.

179 16.

17.

18.

19, 20.

21.

22.

23.

24.


Include more of pulses, green leafy vegetables and milk and milk pro- ducts in the diets of expectant and lactating women.

Preserve the foods when availabie in plenty for use at the time of scarcity.

Cook just that much which can be consumed.

Serve immediately after cooking.

Keep your surroundings clean, Growing children and adolescents need extra food.

The requirements of adolescent children are even greater than those of adults.
Use amla in plenty when available as it provides a lot of Vitamin C. Cook flesh foods properiy as uncooked or half-cooked meats are likely to pass infection and infestation.

INFANTS .

Breastfeed your child at least upto 2 years.

.

Breastfeeding is best.

This prevents diarrhoea.

= N .

> Bottle feeding is dangerous.

Cup and spoon feeding is better than bottle feeding.

If bottle-feeding is followed, sterilize milk bottles properly.

Wash bottle after each feed, w o 7, 8, 9: 10, 11, 12.

13 14.
13 14.

15, 16.

17, 18.

19.

20 .

Give him porridge when he is four months old.

.

Add soft, mashed foods — at least two different kinds e.g, cereals and legumes, in infant's diet from four to six months onwards.

Feed twice a day.

Add another one or two foods from six months onwards.

Feed 4 timesa day.

Continue to feed your child when he is sick.

Sick children need feeding.

When your child is sick, seek help from the nearest health centre as early as possible.
When your child has diarrhoea or vomiting, give him extra water, Salt and sugar water can cure dehydration in children.

Get your child immunized.

Make your child play in a clean place.

Prevent diarrhoea by keeping dirt out of a child's mouth.

Flies should not get to a child’s food.

Prevent infection by washing your hands before preparing food.

Wash your hands and your child's hands before feeding him.

Give your child clean water to drink.

Bathe your child daily.


Introduce egg slowly in the diet of infants as it may cause allergy to some infants.

Start with egg yolk.

ill PRESCHOOL CHILDREN ¥ 2.

3.

Give some good quality protein to help the growth of young children such as milk and milk products, egg, fish etc.

Include more of pulses, groundnuts, milk and milk products, green leafy vegetables in the daily diet of children.

Give seasonal fruits like guava, mango, banana etc.

when cheap to your children.


180 - Include orange, red and green coloured vegetables and fruits in child- ren's diet.

n a .

Give food five to six times a day to young children, .

Cereal-pulse mixtures such as khicheri, missi-roti, idli etc.

are espe- cially good for children, Addition of leafy vegetables further improves its quality .

Include da!

and green leafy vegetable preparation in children’s diet.

.
.

Give handful of roasted bengal gram and jaggery daily to young m o children Use groundnuts after removing their red skin for children, .

Give groundnuts in some form or the-other to young children daily.

o a in the case of rice .

Do not overcook the food DON'TS Do not use soda for codking.

It destroys vitamins 3.

Do not throw away excess water after cooking e.g.

Use it in dais, soups, curries or for making dough Do not give spicy food to children till 5 years of age.
Do not starve the child during sickness, Do not force feed infants.

Do not neglect the diet of pre-school children.

> > N n S H M N O .

Do not stop water and other liquids when child is having diarrhoea or vomiting.

Do not introduce more than one food at a time while feeding infants.

.

Do not rerhove the bran from wheat flour.

11.

Do not throw away the leafy tops of vegetables such as radish, turnips.

12, 13.

14, 15.

16.

17.

18.

19 20.

21.

22.

23.

24.

25, 26, 27, 28.

29. carrots etc.


Use them in the form of bhujia or sag.

Do not remove thick peels from vegetables.

Do not use the same fat repeatedly for frying Do not keep the fat used for frying for long periods Do not keep cut vegetables for long Do not cook milk for long as it destroys its nutrients.

Do not use cracked eggs as they may contain infection.

Do not use stale, spoilt and over-ripe fruits and vegetables.

Do not use cooked food kept fora long time without reheating it.
Do not ignore the extra requirements during pregnancy and lactation, Do not throw away the whey water after making panir.

Use it as a drink or for cooking rice, dal or making doughs, Do not use the milk when it curdles on its own as it may contain some harmful bacteria.

Do not use infested grains.

Do not use kesari dal as it causes crippling disease.

Do not use the green potatoes as they contain poisonous material.
Do not go in for expensive fruits like apples as guavas and bananas are more nutritious, Do not go in for expensive nuts like almonds, cashewnuts etc.

as groundnuts are equally good.

Do not use spoilt kernels of groundnuts as they contain toxic substance.

Do not leave milk in the feeding bottle after child has taken feed as it accelerates the growth of bacteria.

181 ANNEXURE-V DIET INCOMMON ALIMENTS What diet should be given to the patient?

This is a very common question asked to the doctor.
The question assumes a greater importance when due to some reason or the other, one is not in a position to consult a dotcor, which is most often due to financial reasons.

The subject of dietotherapy or treatment of diseases by diet has become very important in recent years.

The dietis not only important in the diseases caused primarily due to nutritional deficiencies but has an important rolein the management of other diseases also such as Diabetes, Obesity, Gastri- tis, Peptic Ulcer.

Jaundice etc.
Jaundice etc.

itis, therefore, important to know the princi- ples involved in the dietary treatment of common ailments so that one knows what to eat.

The belief that no food should be eaten during sickness, is not only harmful to the patient during sickness but also makes the recovery difficult.

In the earlier days, many patients were cured of Typhoid but died of starvation or malnutrition because a very little food was given to them.
The dietary management in some of the common ailments is discussed below: Fever: Fever for 2-3 days without any complication or fever with cold is one of the mostcommon ailments.

During fever, the body temperature is raised indicating that the energy expenditure rate is increased.

Besides there is increased wear and tear of the tissues.

In order to ensure that the patient's body is not wasted in fever, more calories shoula be given.
If the patient is kept only on liquid foods during the fever, the patient will lose weight.

A good amount of protein is required for the repair ol the body tissues.

It is advisable to include some amount of animai protein in the patient's diet such as milk and milk products, meat, fish, egg etc.

as these help in quick recovery.

The digestion power is slightly reduced during fever.

It is, therefore, necessary to include easily digestible and properly cooked foods in the patient's diet.
Fried foods, spices and condiments etc.

should be avoided.

Plenty of fluids should be taken to wash off the waste materials produced in the body as a result of fever, The diet should have enough of vitamin rich foods, specially citrous fruits containing vitamin 'C’ such as orange, lime, iemon juice etc.

Foods like boiled rice, chapatis, toast with jam, jelly or.

butter, dal soup, boiled potatoes, carrots, milk, curd; fruit or fruit juices, can be included in the patient's diet.
Small amounts of easily digestible foods should be given 182 at frequent intervals.

If these prinicples are followed, the patient will not complain of weakness after recovery.

Diarrhoea: This is another common compiaint specially among infants and children.

3. or more loose or watery stools in aday can be considered as Diarrhoea.

In very acute diarrhoea, since the patient loses a large amount of water and electrolytes from the body, he is weak and js likely to be dehydrated.
Water and fluids are, therefore, greatly needed for his recovery, particularly in the case of children.

The following should be given during acute diarrhoea :— — Boiled and cooled water with or without the addtion of sugar and a little salt to it.

— Oral Rehydration Solution.

— Breast-feeding of infants should be continued.

— As the condition of the patient improves, diluted milk, glucose drink, curd prepared into saltish butter milk, barley water, albumin water etc.

can be given.
can be given.

This should be continued for about 12 hours or so and the diet should be gradually built up from the liquid foods to semi-solid foods and then to solid stage, Foods like soft cooked rice, toast with jam or jelly, milk or curd, soft boiled egg, paneer, custard, soft fibreless, seedless fruit or fruit juices, boiled or lightly cooked vegetables like potatoes, carrots, pumpkin etc., fish or meat lightly cooked should be included in the patient's diet.
Fried foods, spices and condiments, nuts and oilseeds etc.

should be avoided during Diarrhoea.

Dyspepsia: Dyspepsia means indigestion or difficulty in digestion.

Symp- toms like nausea, heart-burn, epigastric pain, discomfort or distention is is aisually due to irregular dietary habits, worries, called dyspepsia.

It immodefate smoking or taking too much of alcohol.

Diet plays a significant role in the management of dyspepsia.
The patient should be assurea thata ‘Bland Diet’ fora few days may Clear up dyspepsia rapidty.

The following rules should be observed: — Avoid heavy meals, fried foods, spices and condiments and any articles of food which one finds disagreeable to him, — Avoid stimulants like alcohol, strong tea, coftee, gravies and soups made from meat extracts.

— Avoid raw vegetables such as cucumbar, onions,radish étc.

— Drink plenty of water between the meals.

— Stomach should not be kept empty farlong.


Smail meals should be taken every 2-3 hours, — Milk and curds should be taken liberally.

— Avoid rush and hurry before and after meals.

Gastritis: It is the inflamation of the gastric mucosa (lining of the stomach).

Clinical feature of Gastritis vary from anorexia (lack of appetite), vague discomfort, nausea and hear!

burn to severe and repeated vomiting accompanied by diarrhoea if there is associated enteritis (inflamation of the intestines).
In acute cases, attention should be focused on the prevention of the serious complications like dehydration and the loss of electrolytes associated with excessive vomiting.

The person should be given plenty of water or water with the addition of a little salt and glucose or fruit juices.

On 183 improvement of the patient's condition, small feeds of barley water, whey or milk can be given and gradually switch over to a ‘Bland Diet’.
Peptic Ulcer: The ulcer is commonly found in the stomach or in the duodenum, Some of the possible irritants are strong tea or coffee, alcohol, cigarette smoking etc.

Stress and strain and hurried and irregular meals are important contributory factors.

A ‘Bland Diet’ given in small amounts at short intervals is advised.

Diet as indicated in the management of dyspepsia is to be followed.

Obesity : (Over-weight) : Obesity is a state in which an excess of fataccum- ulates in the body.
The degree of obesity is assessed by comparing a person's weight with the standard weight for height and age.

The person is referred to as 10%, 20% or 30% over-weighi.

Obesity can arise only when the intake of food is in excess of physiologi cal neéds.

Various factors such as age, sex, eating habits, physical activities physiological, endocrine and genetic factors influence the incidence of this disease.
Obesity can occur in either sex but is usually more commen in women, in whom itis liable to occur after pregancy and at the menopause.

It is also.

common in people who lead asedentary life.

The cause of obesity is teo much food and too little exercise, Apart from aesthetic consideration, obesity leads to mechanical disabili- ties, pre-disposes to diseases like heart ailments, diabetes etc.

and thus reduces the expectancy of life.

The successful treatment of obesity requires strict diet control.
Theintake of energy rich foods|like pure carbohydrates (sugar, honey etc.

), starchy foods (potato, colocasia, cereals etc.)

and fats must be reduced.

The protein content of the diet should be sufficient.

The diet should contain plenty of green leafy vegetables and fruits as they provide little energy while their bulk helps to satisfy the hunger.

A plate of salad before each meal helps to reduce the intake of cereals and energy rich foods.
Raw vegetabies also help to relieve constipation which is a common problem on a low food intake, Care should be taken that there is no decline in the physical activity Since obesity is the result of wrong eating habits, spread over along span of time, the reduction in weight cannot be achieved overnight.

In fact, sudden reduction in weight can be dangerous.

The weight reduction process should be a gradual!

one and should be achieved through reduced energy intake and increased physical activity.
Cardiac disease (Heart disease); There are various forms of cardiac disease.

Atherosclerosis and hypertension are the principal causes of heart disease.

The thickening of the walls of the blocd vessels is the main feature of atherosclerosis.

The thickening occurs due to the accumulation of fatty substance known as cholesterol in the inside of the blood vessels.

Chaies- terol is always present in the body —a part of itis manufactured in the body and 2 part is supplied through the diet.
Clinical manifestations of the disease vary depending on the blood vessels which get affected by atheros- clerosis.

lf coronory arteries are affected the heart muscie suffers from lack of oxygen thus giving rise to various forms of coronary heart disease.

if the uw of blood is blocked due to clot in these arteries, it results in heastattack.

184 The clinical symptoms include classic chest pain which usually occurs at rest or during sleep.

Apart from pain the patient may sweat or vomit and be restless.
There are various factors — both non-controllable and controllable fac- tors — known to be responsible for heart disease.

The non-controllable factors include heredity factor, increasing age of the person and sex (risk being greater for men).

The controllable factors include diet, sedentary life, smoking, stress and strain, high blood pressure, obesity etc.
Prevention against heart disease, therefore, entirely depends on avoiding the ‘risks’ arising from controllable factors, The diet has an important role in the prevention and management of heart disease.

The three important dietary factors which require special consid- eration are cholesterol, fat and totai calories.

Some of the general rules for planning the diet for a heart patient are; — Reduce the intake of animal fats such as butter, ghee, vanaspati (hydro- genated fat), coconut oi!
and substitute these fats with the vegetable oils like safflower oil, gingelly oil, — Reduce the intake of food to avoid gain in weight since over-weight results in greater strain on the heart and favours heart disease.

Reduc- tion in food intake becomes essential since there is curtailment in the physical activity of person suffering from heart disease.

— Since hypertension (high blood pressure), one of the important risk factors in the causation of heart disease, is believed to be related to sa!!
intake, the salt used in cooking must be reduced to a minimum.

Salt rich foods such as butter, cheese, sauces, pickles, salty biscuits should oe avoided.

— Regulate the meal pattern.

A heart patient should have small meals at frequent intervais.

— Avoid tatty foods and rich foods such as fried foods, ice creams, sweets etc.

— Foods like vegetables except roots and tubers, fruits, soups without fat, tea and coffee, tomato juice, lemon, lemon juice, spices can be allowed freely.
Adequete care with regard to diet avoiding obesity and leading an active but a reasonably calm life are the best measures for prevention of heart disease Diabetes is also known as sugar disease since the level of Diabetes: giucase (sugar) in the bloodand urineincreasesin this condition Glucose is the major body fuel tor supply of energy.

Insulin, aharmonesecreted by the pancreas, is essential for glucose utilitsation in the body.
A delayed or reduced release of insulin from the pancreas constitutes the cause of diabetes.

The normal level of glucose in blood during fasting state is between 65 and 100 mg. per 100 mi.

of blood.

The clinical symptoms results from inability of tissues and cells to utilise glucose.

Excessive thirst, frequent urination particularly during nights, loss of weight, weekness, frequent changes in eyesight, slow healing of wounds etc.

are some of the symptoms of diabetes.

Diabetes is usually inherited.


The diet has an important role in the management of diabetes.

In other words, the treatment of all diabetic patients requires some dietary restric- tions if control is to be satisfactory.

By regulating the amountand the times of food intake, particularly the carbohydrate intake, an attemptis made to 185 achieve a flat profile of blood glucose level throughout the day and night.
Some of the general considerations while planning diabetic diets are: — The carbohydrates in the whole day's diet should be equally distributed in the 3 main meals and some provided for snacks at mid morning and evening tea.

— Theconsumption of protein needs to be enhanced.

Some protein should be taken at each meal.

— Prepare chapatis by mixing wheat flour and Bengal gram flour in the ratio of 2:1 0r3:1.

This helps in reducing the carbohydrate intake and increas- ing the protein intake.
— Most ofthe fat calories should come from polyunsaturated fats i.e fats of vegetable origin, — The fibre content of the diet has been shown to have beneficial effect in the control of diabetes.

Raw fruits and vegetables, whole wheat flour and cereals are important sources of dietary fibre and should, therefore, be consumed daily.

— Intake of vitamins and minerals should be adequate.

Protective foods like green leafy vegetables, other vegetables, citrous fruits, milk and milk products should be consumed.
— Sugar, jaggery, sweet preparations and alcohol have to be avoided.

Artificial sweetner like saccharine could be used.

— Avoid roots and tubers, fried foods, dried fruits and nuts and fruits like banana, grapes, mango etc.

— Diabetic patients should never resort to total fasting as the resulting low blood glucose level can also be dangerous.

Jaundice: Jaundice occurs during the acute stage of both toxic and intec- tive hepatitis (inflamation of the liver).
Toxic hepatitis is due to poisoning with metals e.g.

arsenic,mercury, copper etc whereas infective hepatitis is generally due to viral infection.

The clinical symptoms of acute hepatitis include loss of appetite, intense nausea, fever and yellow colouration of the skin particularly of mucous memebrane of the eye and yellow or dark brown urine.

The diet has an important role in the management ofJaundice.
Some of the general rules for planning a diet for aJaundice patient are: — Ahigh carbohydrate intake is essential, not only as a source of calories but also for its proven value in the treatment of injury to liver cells, To secure a high intake of carbohydrate, sweetened fruit drinks such as sugarcane juice, fruit juices, orangeade, lemonade or glucose drink should be taken liberally.
— The fat content of the diet should be drastically reduced because when jaundice is marked and nausea and lack of appetite are present, fat and fatty foods are poorly tolerated.

In addition, the absorption of fat from the intestines Is impaired because of the lack of bile salts.

— |n severe cases of jaundice, the protein content should be severly res- tricted or totally forbidden.
When the condition of the patient improves, some amount of good quality protein should be given, In mild and moderate cases, an adequate intake of protein is desirable.

— High calorie intake is important in accelerating recovery.

Rest in bed is essential for the recovery of the liver cells and should be continued until the appetite has returned.

186 le EXPLANATORY NOTE ON ASSESSMENT OF NUTRITIONAL DEFICIENCIES ANNEXURE - VI |.

Protein-Energy Mainutrition (PEM).


There are two major syndromes of protein- energy malnutrition of early childhood viz.

Kwasnhiorkor and Marasmus.

1.

Kwashiorkor The early signs of Kwashiorkor are: (a) Growth retardation or growth failure The first sign a child may show is growth retardation or growth failure.

There is low body weight for age.

Children at 18 months may weigh not more than they did at 9 months.
(b) Loss of subcutaneous tissue Tnere is loss of subcutaneous (below the skin) fat and the child’s arm and legs are thin.

The circumference of the upper arm is reduced, The skin is loose, thin, wrinkled and inelastic (c) riair changes {i} |Dyspigmentation of the hair: The hair becomes light brown in colour: (ii) Easy pluckability of the hair: If the hair is pulled, it comes out easily.

The hair starts falling.

Thin sparse hair: Hair becomes fine, straight, brittle and loses its (ili) curl and lusture.
Hair is thinly distributed (baldness).

187 (d) Moon tace The child's face looks as round as a moon.

The cheeks look very fluffy.

The overall appearance of the child is not healthy.

The late signs of Kwashiorkor are: (e) Oedema There is swelling of the feet, lower part of the legs and often the hands.

It can be detected by putting pressure with a finger on the lower portion of the leg for 3 seconds and if the depression (pit) remains after removing the pressure, the sign is taken as positive.
(f} Mental changes The child becomes inactive and irritable, He is dull and withdrawn and makes few attempts to walk or move about.

General apaihy and refusal to food is very common, (g) Skin changes There is hyperpigmented (dark coloured) patches of skin.

In severe cases, these turn into ulceration ane fail off thus giving alook of aburn.
In other words, the skin becomes spotted, scaly and may become broken and appear like a burn, It can occur anywhere but the legs, buttocks and perineal areas are most frequently involved.

Besides this, the growth retardation, loss of subcutaneous fat and other signs are more marked in later stages.

(2) Marasmus The early signs of Marasmus are: .

(a) Growth retardation or growth failure Growth retardation is very much marked in the case of Marasmus.
The child is usually below 60% of the standard weight for that age.

(b) Wasting of muscle and subcutaneous fat The arms get very thin.

The skin is loose; thin, wrinkled and inelastic.

The child looks like a ‘little old man’.

The wasting of muscle is very prominent on the buttocks, The fate signs of Marasmus are: (c) Severe growth retardation.

The growth retardation is extreme.

A child of 4-5 years may weigh only 2-3 kgs.


(9) Extreme wasting of muscle and fat The child looks like a skeleton with only skin and bones.

It Vitamin ‘A’ deficiency A few signs suggestive of Vitamin A deficiency are: (a) Night blindness There is difficulty in seeing clearly in dim light or at night.

The person's activities during this time i.e.

after dusk, are curtailed as he cannot see objects clearly.
However, night blindness should be recorded as posi- tive only after a careful evaluation of the history given by the mother.

188 (9) 81005 spots Greyish, silvery or chalky white, dry, foamy patches on the sides of cornea on the conjunctiva (on the white portion of the eye) are Known as Bitors spots (c) Keratomalacia The cornea (black portion of the eye) softens leading to complete blindness, The condition is insidious at the onset.
There is no pain or other camplainis, The condition needs urgent attention by the doctor, Ill Riboflavin deficiency Some of the signs suggestive of this deficiency are: {a) Angular stomatits There is ulceration and tissuring al the angles of the mouth.

The sign is reported as positive only when both angles of the mouth are involved.

(b) Cheilosis The lips are cracked (vertical fissuring) red and swollen.

There may be ulceration also other than at angles.


The centre of the lower lip is most usually affected (c) Glossifis (red and raw tongue) The tongue may be bright red in colour, denuded (bald |.e.

smooth) and paintul, IV.

Nicotinic acid (niacin) deficiency Pellagra The deficiency of nicotinic acid causes Pellagra.

In Pellagra, skin lesions (dermatitis) are mainly found on the exposed parts of body to sunlight like hands, feet, legs and neck and sometimes involving face also.
One peculiar thing about these skin lesions Is that these are found symmetrically te.

on both hands, both feet, The area becomes red, swollen and cracked.

There is itching and burning sensation.

V_ Vitamin C deficiency Spongy bleeding gums The pointed ends of the gums in between the teeth become swollen and red Or purplish in colour.

If the.gum margins are pressed slightly with the thumb or finger these start bleeding.
Presence or absence of gingivitis (infection of gums) must be noted since the infections can also produce the same condition.

Vi Vitamin D deficiency The deficiency of Vitamin D causes rickets which can be diagnosed trom the following signs: (8) Epiphyseal enlargement Enlargement of the ends of long bones, particularly affecting the long bones of the forearms and forelegs at the level of wrist and ankle respectively.

This enlargement is painiess.


189 (b) Beading of the ribs There are rounded projections on the ribs on both sides of the chest, This can be easily detected by passing fingers on the ribs when the child is in lying position.

There is one projection in one rib thus giving a “peaded” or “rosary” effect.

It is also known as “ricketty rosary”.

(c) Knock knees or bow legs In knock Knees, the knees touch each other and the forelegs diverge from the knees.
In bow legs, the legs get bent and knees are far apart from each other.

(d) Hypotonia The muscles become weak and the child is unable to sit and walk, Vil tron deficiency lron deficiency causes “Anaemia”.

A few signs suggestive of iron defi- ciency anaemia are.

(a) Pale conjunctiva The conjunctiva of the eyelids turn pale.

This paleness can also be seen in the buccal mucosae, skin and nails.

(b) Kollonychia The nails become dry and brittle.


There is flattening and thinning of the nails and finally they become spoon-shaped i.e.

the surface of the nails become concave instead of convex.

The sign is taken as positive when nails of both feet show this deformity.

(c) Atrophic lingual papillae (smooth, bald tongue) The tongue becomes pale and develops a smooth, shiny appearance.

Theatrophy of the papillae begins at the edges of the tongue and later affects the whole tongue.
Vill Age, height and weight (a) Age assessment The age should be recorded till the last birthday of the child and wher- ever possible till the last month since exact age is important to co-relate with height and weight.

The use of local calendars and festivals may be utilised for assessing the correct date of birth of the child.

(b) Weight If spring balance Is used, it should be checked against known weight frequently.

The child should be weighed without shoes and with light clothing.
(9) Height After removing the shoes, the child should stand on a flat flooragainsi a wall with feet parallel and with heels, buttocks, shoulders and back of head touching the wall.

The head should be held comfortably erect and a mark made on the wail with the help of a scale touching the top of the head horizontally.

The height should be measured in centimeters with the help of a steel measuring tape so as to avoid error due to looseness of the ordinary tape.
190 BIBLIOGRAPHY ANNEXURE-VII Annual Report 1984-85, Department of Rural Development, Ministry of Agriculture and Rural Development, Govt.

of India, New Delhi.

Annual Report, Ministry of Health & Family Welfare, 1984-85.

Diarrhoea in children, Ministry of Health & Family Welfare, 1982.

FAO Food and Nutrition Papers: 10, Prevention of Mycotoxins, FAQ 1979.
FAO/WHO Codex Alimentarious Commission, Proposed Draft Code of Hygiene, Practice for pre-cooked and cooked meals in Mass Catering, Foider on Save Your Child from Nutritional Blindness, WHO/UNICEF, 1986 Food & Health, NIN, ICMR, 1979.

Focd & Water Borne Diseases by A.K.

Mallick, Group Nutrition Interven- tion.

Management Manual, Department of Food, New Delhi.

191 Fundamentals of Food and ae By Sumati R. Mudambi, M.V.

Rajagopal, 1981.
Rajagopal, 1981.

Guidelines for training Community Health Workers in Nutrition, WHO Offset publication No.

59, World Health Organisation, Geneva, 1981.

Handbook for Nutrition Trainers of Anganwadi Workers, National Insti- tute of Public Cooperation & Child Development, 1984.

Handbook of Health Statistics in India, 1985, Central Bureau of Health intelligence, Directorate General of Heaith Services, Nirman Bhavan, New Delhi.

Human Nutrition & Dietetics by Sir Stanley Davidson & R, Passmore, 1966.
Integrated Child Development Services, Ministry of Human Resource Development (Department of Women & Child Development) Govt.

of India, 1986. lodine Deficiency Disorders in South-East Asia, Searo Regional Health Papers No.

10, World Health Organisation, Regional Office for South- East Asia, New Delhi, 1985.

Manual for Community Health Worker, Ministry of Health & Family Welfare, New Delhi, 1977.

Manual for Health Workers — Vol.

|, Ministry of Health & Family Plan- ning, 1977.


Manual for the Health Guides, Ministry of Health & Family Welfare, 1982.

Manual of Nutrition, NIN, ICMR, 1982.

Nutrition and Goitre Situation in India, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt.

of India, New Delhi, 1986.

Nutritive Value of Indian Foods, National Institute of Nutrition, ICMR, New Dethi, 1985.

Paper on ‘Feeding Young Children’ by Smt.


Shashi Prabha Gupta, ‘Kurukshetra’ (India’s Journal of Rural Development) Vol.

XXXII, No.

2, November, 1983.

Public Health Nutrition in Developing Countries, Dr. Kalyan Bagchi, 1986.

Safe Water & Clean Surroundings, a CHEB's Bulletin, DGHS, New Delhi.

The Feeding & Care of Infants & Young Children by Dr. Shanti Ghosh, 3rd Edition, 1980.
The Health Aspects of Food & Nutrition, WHO Publication (3rd Edition), 1979, The Immunization Programme in India, a Handbook for Medical Offic- ers by Jotna Sokhey, Indra Bhargava, R.N.

Basu, Government of India, Ministry of Health & Family Welfare, New Dethi, 1984.

The Nutrition Factor by Alan Berg, 1973.

Towards the Implementation of a National Nutrition Policy in india, Report of-a National Seminar held in Srinagar, October 28th to 30th, 1986, Indian Council of Medical Research, New Delhi, 1986.
U.S. Department of Health, Education and Welfare, Sanitary Food Ser- vice, Instructors’ Guide, 1969 Revision, Your Health & Nutrition by V, Ramadasmurthy & M. Mohan Ram — National Institute of Nutrition, ICMR, Hyderabad, 1984. e e p — + + » त र — ~ printed at Veeremiea Printers, New Dethi-110005,