UNIT 1 CHILDHOOD CRITICAL PERIOD OF LIFE CYCLE

Structure 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Introduction Infancy, Childhood and Adolescence- A Critical Period of Life Neonatal and Childhood Mortality
1.3.1 Causes of Neonatal Death

Child Survival Pediatric Nutrition: Scope and Perspective Let Us Sum Up Glossary Answers to Check Your Progress Exercises

1.1 INTRODUCTION
There is a vital link between nutrition, productive and a healthy life. Good nutrition is essential for survival, physical growth, mental development, performance, productivity, health and well-being across the entire life-span starting from the earliest stage of foetal development, whether at a time of birth, or through infancy, childhood, adolescence and on into adulthood. Though optimal nutrition is important for all through the life cycle, it is much more important during infancy, childhood and adolescence - the critical period of life. Have you ever thought why exactly these periods are considered as critical periods of life cycle and why one should invest so much care during these periods? We begin our study of Pediatric Nutrition with this unit by first familiarizing ourselves with the critical periods of life i.e. infancy, childhood and adolescence. We will discuss various important aspects related to each of these critical periods. A detail review on neonatal period and neonatal mortality has also been included. Further, a separate section on the child survival has been presented to give you a broad idea of the child health scenario and the practical interventions available to improve child survival. Pediatric nutrition as a new emerging sub-specialty is the other focus area of this unit. There is a defined area of pediatric care that requires nutrition expertise. The scope, perspective of pediatric nutrition has been highlighted wherein you will get an insight into the aspect that does nutrition matter in terms of long health and development. Read and find out.

Child Growth, Development and Nutritional Status

Objectives
After studying this unit you will be able to: identify and explain the critical periods of life cycle, elaborate on the concept, terminologies linked with neonatal period, discuss the issues linked with child survival, and appreciate why pediatric nutrition is emerging as a new sub-speciality in pediatrics.

1.2 INFANCY, CHILDHOOD AND ADOLESCENCE- A CRITICAL PERIOD OF LIFE

Refer to Figure 1.1 which illustrates the critical periods in the life cycle, from the time before birth till adolescence. Starting with the prenatal period (i.e. pregnancy - the time from conception to birth), a period, as you may already be aware is characterized by tremendous growth - from a single cell to an organism, complete with organ, organ systems and behavioral capabilities and produced approximately in a nine month period. The foetal stage and the initial 1000 days after birth are nutritionally critical for the child to grow normally as this is the period when the body and the brain develops at a fast pace. Did you know that the origin of many lifestyle diseases in adults can be traced to bad nutrition in the foetal stage?

Figure 1.1: Critical periods in the life cycle

The term perinatal pertains to the period immediately before and after birth. If you were to review the literature you would realize that perinatal period is defined in diverse ways. Generally it is considered the period extending from

28th week of gestation onwards and ends one to four weeks after birth (neonatal period). The perinatal period is critical time, when the foetus, who is adapted to life inside its mothers womb, must suddenly at birth be able to survive in a totally different environment. Neonate refers to a child less than 28 days of age. The neonatal period commences at birth and ends 28 completed days after birth. The neonatal period (birth to 28 days) can be divided into two distinct phases: the first seven days (early neonatal period) and the remaining three weeks (late neonatal period). You can have a better understanding of the neonatal period from the illustration presented in Figure 1.2. A detailed review on the neonatal period is presented later in this section.

Childhood- Critical Periods of Life Cycle

Figure 1.2: Perinatal and neonatal period Source: Indira Narayanan, Mandy Rose, Dilberth Cordero, Silvana Faillace, and Tina Sanghvi. The Components of Essential Newborn Care. Published by the Basics Support for Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International Development. Arlington, Virginia, June 2004.

Infancy is the developmental period that extends from birth to 12 months of age, which includes the neonatal period (first 28 days of life). It is important to understand that infancy is the basic foundation period of development, in fact of survival. This period is characterized by rapid growth and is accompanied by major changes in body composition. A detail review on infancy the critical period is included later in this Course in Module 4, Unit 2. Foetal and infancy period is the specific time during which nutrition has its greatest impact on the individuals growth and development. Exclusive breastfeeding and timely introduction of appropriate complementary foods are essential for nutritional adequacy during this period. Module 4 (Unit 3 and 4) later in this Course focuses on these aspects. Foetal and the infancy period is the time when maternal health/nutrition also has its strongest influence. Studies show that womens health throughout the life cycle, from childhood through adolescence and into adulthood, is critical in determining the neonatal and the infant health outcomes. Further, it is during the period of infancy and early childhood that irreversible faltering in linear growth and cognitive deficits are seen to occur. Childhood period is divided in to three stages i.e. early, middle and late childhood. Early childhood is the developmental period that extends from the end of infancy to about six years, referred to as the preschool years. Middle

Child Growth, Development and Nutritional Status

and late childhood is the developmental period that spans from about six to eleven years of age, approximately corresponding to the elementary years; sometimes the period is referred to as the school years. Though this period witness slower growth than infancy (in terms of body size and proportions), still occasional growth spurts may occur. When considering the importance of nutrition during childhood, one should not forget about its influence on health later in life. Inadequate dietary intakes have a detrimental impact on a childs health and may lead to under nutrition level. Early childhood undernutrition subsequently results into stunting, slow physical growth, and other manifestations which affects the development of all organs and systems of the childs body. Along with energy deficient diets, lack of certain other micronutrients, nutrients may also lead to micronutrient deficiency, disorders and increase vulnerability of children to poor health. Undernutrition when coupled with poor health care services mostly leads to increased risk of infant and child morbidity and mortality. A detailed review on this aspect you will find in Unit 2 later in this module. Adolescence: World Health Organization (WHO) has defined adolescence as the period between 10 and 19 years. Adolescence is the transition between childhood and adulthood and is one of the most dynamic periods of human development. In adolescence, rapid growth takes place which is second only to the growth that occurs during the first year of life, and it increases the bodys demand for energy and nutrients. Adolescence is nutritionally critical period of life for the very prime reason of the dramatic increase in physical growth and development. Skeletal and sexual maturation occur which puts greater pressure on the need for nutrients. Adequate nutrients are required to meet the needs of growth and facilitate efficient mental and physical development. Adolescence is the developmental period of transition from childhood to early adulthood. Teenage girls are extremely vulnerable and face many challenges to their health and well-being. Early marriage and lack of access to contraception or safe abortion care means that adolescent girls experience disproportionately high rates of intra-partum complications, still births, neonatal deaths, prematurity and low birth weight. It is to be noted that we have tried to familiarize you broadly with the critical life periods. However, detailed aspects of each life period with context to growth/development and nutrition will be dealt in later units of this course. Here as mentioned earlier we shall like to review the neonatal and childhood mortality estimates and direct causes of neonatal deaths, next.

1.3 NEONATAL AND CHILDHOOD MORTALITY

Newborns continue to be at risk during the first week of their life, after which their chances of survival improve markedly. Neonatal deaths generally is subdivided into early neonatal deaths, occurring during the first seven days of life and late neonatal deaths, occurring after the seventh day but before the 28 completed days of life. Neonatal mortality is defined as the probability of a newborn dying between birth and the first 28 completed days of life. Neonatal mortality rate, on the other hand, is the number of deaths during the first 28 completed days of life per 1,000 live births in a given year or period.

A brief review of the infant and child mortality indicators is presented in Box 1.1. Box 1.1: Infant and Child Mortality Indicators Neonatal mortality Postneonatal mortality Infant mortality Child mortality Under-five mortality : : : : : The probability of dying in the first month of life The probability of dying after the first month of life but before the first birthday The probability of dying before the first birthday The probability of dying between the first and fifth Birthdays The probability of dying before the fifth birthday

Childhood- Critical Periods of Life Cycle

According to World Health Report 2005, it is estimated that each year nearly 3.3 million babies are stillborn, and more than 4 million others die within 28 days of coming into the world (i.e. the Neonatal period). Out of 4 million neonatal deaths worldwide, India is accounting to 1.2 million or nearly 30% of global neonatal mortality. Even though the infant mortality in India has declined from 77 deaths per 1,000 live births in 1991-95 to 57 deaths per 1,000 live births in 2001-05, implying an average rate of decline of 2 infant deaths per 1,000 live births per year, still there is a long way to achieve the goals set up by Government of India of reducing the infant mortality rate to 30 per 1000 live births by the year 2010. According to the National Family Health Survey 3 (2005-2006) estimates (Figure 1.3), 39 neonates die per 1,000 live births is too high. There is a great diversity of Neonatal Mortality Rate in different states of India and the states of Bihar, Madhya Pradesh, Uttar Pradesh and Rajasthan together constitute over half of all newborn deaths in India. Also in both the neonatal and postneonatal periods, mortality in rural areas is higher than mortality in urban areas. Current status of newborn, postneonatal, infant and child mortality rate in India is presented in Figure 1.3. In 2008, 1.8 million children, age < 5 years, including 1.5 million neonates, died. About a third of all neonatal deaths occur on the first day of life. Approximately an additional one third of deaths occur between the first and seventh day of life. The current neonatal mortality rate (NMR) of 35 per 1,000 live births accounts for nearly two-thirds of all infant mortality and half of under-five child mortality. Recent estimate of infant mortality is 53 deaths per 1,000 live births (Table 1.1). It is to be noted that every sixth death in the country pertains to an infant. The statistics presented indicate India still has a long way to go to reach the goals and target (Table 1.1). The Millennium Development Goal for child survival cannot be met without substantial reduction in neonatal mortality.

Child Growth, Development and Nutritional Status

Figure 1.3: Early Childhood Mortality Rates for the Five-Year Period preceding the Survey, NFHS-1, NFHS-2, and NFHS-3

Table 1.1: Key indicators and current status and national goals for newborn and child health
Indicators Child (Age <5 years) mortality rate Infant mortality rate (IMR) Status (year) 74 per 1000 live births (2005-06).1 69 per 1000 live births (2008),
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Goals and targets (year) Millennium Development Goal 4: 38 per 1000 live births (2015)

63 per 1000 live births (2010)3 53 per 1000 live births (2008)2 National Population Policy (2000) and National Rural Health Mission: <30 per 1000 live births (2010); XI Plan: 28 per 1000 live births (2012) National Plan of Action for Children 2005: 18 per 1000 live births (2010) National Plan of Action for Children 2005: reduce by half (2010); Millennium Development Goal 1: 27% (2015)

Neonatal mortality rate (NMR) Prevalence of underweight among children (age <5 years)
1. 2. 3.

35 per 1000 live births (2008)2

43% (2005-06)1

Source: 1: National Family Health survey (NFHS-3), 2005-06, India: Volume Mumbai: International Institute for Population Science and Macro International, 2007. Registrar General of India. Sample Registration Survey (SRS), Statistical Report 2008. New Delhi: Registrar General of India, 2009. Neonatal, postnatal, childhood and under-5 mortality for 187 countries, 1970 2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet 2010: 375:1988-2008.

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What are the causes for such high neonatal mortality? We shall review the causes of neonatal mortality, next.

Childhood- Critical Periods of Life Cycle

1.3.1 Causes of Neonatal Death

There are a number of direct and indirect causes of neonatal deaths. Here in this sub-section our focus of discussion would be direct causes of neonatal deaths. Globally, the main direct causes of neonatal deaths are estimated to be pre-term birth (27%), severe infections (26%), and asphyxia (23%) as highlighted in Figure 1.4. Neonatal tetanus accounts for a smaller proposition of deaths (7%), but is easily preventable. Low birth weight (<2500g) is an important indirect causal factor in 60 -70% neonatal death. Low birth weight (LBW) can be an outcome of pre-term birth (gestational age < 37 completed weeks) or prematurity (Intrauterine Growth Retardation (IUGR)) or both. In the developing countries (Including South Asia) majority of LBW are IUGR. In India, two-third LBW neonates fall in IUGR category. It is important to highlight here that IUGR is caused predominantly by maternal malnutrition, either before conception or during pregnancy.

Figure 1.4: Direct causes of neonatal deaths Source: 4 million neonatal deaths: When? Where? Why? The Lancet, Vol 365, No.9462 (2005), p 895.

Neonatal death is closely linked to the health and nutrition of the mother and the care she receives before, throughout pregnancy, through delivery and after birth, that is, care along the continuum. The concept of care along the continuum is dealt later in this unit in section 1.4. Neonatal care plays a huge significant role for the proper development and healthy life of the baby. However, neonatal care has often received a less optimum attention. Although, over a period of time, various child survival programmes apart from focusing on reducing the death rate among children under age 5, have also been specifically active in bringing a positive change in the neonatal care by making an impact on reducing mortality from diseases and by providing essential newborn care.

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Child Growth, Development and Nutritional Status

Now that you had a brief overview of the critical periods of infancy (including the neonatal period), childhood and adolescence and the significant role which nutrition plays in each life period, the next section will deal with the crucial aspects linked with child survival. Before we move on to this section let us take a break here and recapitulate what we have learnt so far by attempting the Check Your Progress Exercises given next. Check Your Progress Exercise 1 1) Define the following: a) Neonatal mortality rate ... ... ... b) Infant mortality rate ... ... ... 2) Neonatal health is closely linked with the health and nutrition of the mother. Justify the statement. . . . . . 3) Enumerate the critical periods in the life cycle. . . . . . .

1.4 CHILD SURVIVAL

The major crux of discussing the issues of optimal and adequate nutrition during infancy, childhood and adolescence is to improve child survival, not only in terms of numbers but also providing them with healthy life. While dealing with child survival, an understanding of the determinants of child survival and development is also very essential. These determinants include, at

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the most distant level, socioeconomic factors, such as income and education. The immediate determinants consist of nutritional adequacy and health status. You may be aware of the close association between these two factors. The immediate determinants are in turn are influenced by various factors like food security, nutrition and health care services especially in case of women and children. The framework of determinants of child survival and development is best illustrated in Figure 1.5.
Determinants of Child Survival & Development
Survival, Growth & Development Adequate Dietary Intake Health
Manifestation

Childhood- Critical Periods of Life Cycle

Immediate Determinants

Household Food Security

Care for Children and Women

Health Services & Healthy Environment

Underlying Determinants

EDUCATION Resources and Control Human, Economic & Organizational Political and Ideological Superstructure Economic Structure Potential Resources
Basic Determinants

Figure 1.5: Determinants of child survival and development

The continuum of care has recently been highlighted as a core principle of programmes for maternal, newborn, and child health, and as a means to reduce the burden of half a million maternal deaths, 4 million neonatal deaths, and 6 million children who die between the ages of 1 month and 5 years. According to the World Health report , 2005 the term Continuum of care refers to i) care to be provided as a continuum throughout the lifecycle, including adolescence, pregnancy, childbirth and childhood, and (ii) it indicates that care has to be provided in a seamless continuum that spans the home, the community, the health center and the hospital. Figure 1.6 illustrates the concept. The continuum of care approach (Lancet Neonatal Survival series 2007) promotes care for adolescence/mothers (before pregnancy) and children from pregnancy to delivery, the immediate postnatal period (mother/maternal health), and childhood, recognising that safe childbirth is critical to the health of both the woman and the newborn childand that a healthy start in life is an essential step towards a sound childhood and a productive life. Another related continuum is required to link households to hospitals by improving home13

Child Growth, Development and Nutritional Status

based practices, mobilising families to seek the care they need, and increasing access to and quality of care at health facilities.

Figure 1.6: Connecting care giving across the continuum between households, communities and health facilities

Key behaviours and interventions that should be integrated into existing maternal and child health programs to improve newborn health and survival have been identified which are based on the principles of continuum of care. Figure 1.7 illustrates the package of Essential Newborn Care (ENC) basic and special care interventions which have a proven role in promoting health, survival of newborns. Ensuring universal access to skilled care (antenatal, postnatal and labour and delivery care) is the accepted strategy (basic and normal) to make childbirth and the early postnatal period safe for mother and newborn. Simultaneous strategy supporting community-based providers to improve household practices and provide a link between families and the health system is important.

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Childhood- Critical Periods of Life Cycle

Figure 1.7: Interventions for newborn care across the continuum of care Source: Essential newborn care: at a glance (2001). In: Save the Children

Child mortality is closely linked with malnutrition and inappropriate feeding. According to the Global Strategy for Infant and Young Child Feeding, malnutrition, directly or indirectly has been responsible for 60 per cent of the 10.9 million deaths in the year 2000 among children under five. And over twothirds of these deaths, which are often associated with inappropriate feeding practices, occur during the first year of life. The National Guidelines on Infant and Young Child Feeding (2006) also points out that malnutrition among children occurs almost entirely during the first two years of life and is virtually irreversible after that. According to the Lancet Child Survival Series 2003, nutrition plays a significant role in decreasing the child deaths. Receiving oral rehydration therapy as needed for diarrhoea, exclusive breastfeeding during the first 6 months of life; receiving Vitamin A supplementation; access to iodized salt; and addressing the issue of malnutrition are some of the interventions which prove to be beneficial for reducing the child mortality especially in developing countries. The series also provides practical interventions which are available for preventing or treating each of the main causes of death among children younger than five years. The child survival interventions especially those related to nutrition (which includes both preventive and treatment interventions) are enlisted herewith: Breastfeeding (including exclusive breastfeeding for the first six months and continued breastfeeding for the next six months). Adequate complementary feeding between six and 24 months. 15

Child Growth, Development and Nutritional Status

Micronutrient supplementation like Vitamin A and Zinc supplementation. Oral rehydration therapy Immunization

Apart from these interventions, emphasis is also laid on strengthening public health delivery through newer approaches like Integrated Management of Childhood Illnesses (IMCI) which facilitates basic newborn care, management of childhood illnesses and existing health and nutrition programmes. Note, this section provided a brief summary of child health situation, survival and intervention strategies. You may have noticed that nutrition in its broadest sense is very crucial for long term health and development. Benefits of nutritional care are emerging over a broad range of pediatric care. A brief review on pediatric nutrition: its scope and significance is presented in the next section. Going through this section will help you realize how pediatric nutrition is emerging as a defined area of expertise.

1.5 PEDIATRIC NUTRITION: SCOPE AND PERSPECTIVE

Nutrition is a core pillar of human development. From our study so far, it is evident that the provision of appropriate nutrition is of greatest importance during infancy and childhood. This phase of life is characterized by rapid growth and development. Nutrition has its strongest effect during childhood. Nutrition needs of children need to be addressed in an appropriate way right from the beginning. Throughout infancy, childhood and adolescence, the requirements for nutrients and energy change. Requirements for macronutrients and micronutrients are more during infancy and childhood than at any other developmental stage. Infancy is a period of rapid growth, comparatively childhood is a period of slow and irregular growth, and adolescence is a period that consists of a large growth spurt before adulthood. It is these continually changing nutritional requirements during childhood and adolescence that makes these stages of life crucial for proper growth and development. Growth and development during infancy, childhood and adolescence is influenced by nutrition. Moreover during development of the embryo and the foetus important physiological parameters can be reset by the environmental events (such as nutritional deficiencies) and the resettling can be endured into adulthood and even after the following generations to produce transgenerational non-genetic disorders. This is the fetal programming hypothesis. The hypothesis proposes that alteration in fetal nutrition and endocrine status result in developmental adaptations that permanently change structure, physiology and metabolism, thereby pre-disposing individuals to cardiovascular, metabolic and endocrine diseases in adult life. Recent evidence suggests that several of the major diseases of later life, including coronary heart diseases, hypertension, type 2 diabetes mellitus originate in impaired intra-uterine growth and development. This is the factor that has most influenced the interest in pediatric nutrition. There is now a new onus on health and/or nutrition professionals to ensure proper nutrition to optimize the short and long term health of population in general and more specifically the

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pediatric population. Proper understanding and knowledge of nutritional concepts is needed to provide for different growth needs. Growth in early childhood is a health indicator that has been linked more directly to diet and nutritional status. Understanding of the growth and development patterns of children such as height, weight and other anthropometric measurements is of utmost importance in understanding the nutritional status of children. Understanding the basics of child nutrition, from newborns to adolescence, can help children meet their growth targets and live as healthy adults. Proper nutrition in childhood can reinforce lifelong eating habits that contribute to children's overall well-being and help them to grow up to their full potential and lead a healthy life. There is a growing need to provide the children with proper nutrition so as to avoid malnutrition. Malnutrition limits development and the capacity to learn. Although our economy has seen unprecedented growth over the past few years but the economic growth has not been associated with corresponding reductions in the rates of childhood undernutrition. Also at the same time rapid economic development and increasing urbanization have led to a dramatic rise in pediatric obesity among higher socio-economic status groups in some urban areas. Paradoxically, both over and undernutrition are co-existing; with undernutrition taking the upper hand. Undernutrition jeopardizes childrens health, survival, growth and development. Undernourished children may enter the vicious cycle of recurring illness and faltering growth, with irreversible damage to their cognitive development. Undernutrition in early childhood has serious, longterm consequences because it impedes motor, sensory, cognitive, social and emotional development. At the same time there looms the threat of infectious diseases affecting the children as they have a more serious and protracted course in undernourished children. Undernourished children are less likely to perform well in school and more likely to grow into malnourished adults who are at greater risk of disease and early death. There is a growing need to provide the children with proper nutrition so as to avoid malnutrition. Evidence suggests that deficiencies of nutrients at critical periods can have long-lasting effects on health and development. Vitamin and mineral deficiencies also affect childrens survival and development. Anaemia in young children is a serious concern, because it can result in increased morbidity from infectious diseases and impaired cognitive performance. Proper knowledge of macro and micro nutrient requirements and deficiency is of vital importance. Pediatric obesity is an emerging problem in developing countries, especially among higher socio-economic status groups. Childhood obesity is now being considered a major health hazard. Eating habits of children residing in urban areas are inclined towards low nutritional value energy dense fast foods. Increase in consumption of junk food, as well as, the sedentary lifestyle among children is a main cause of concern as this is leading to rise in pediatric obesity. Obese children will tend to become obese adults and they would be at a high risk of suffering from diabetes, stroke, liver diseases, infertility, hypertension, arthritis and cancer. They may also have a high risk of development of early heart diseases.

Childhood- Critical Periods of Life Cycle

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Child Growth, Development and Nutritional Status

Maternal nutrition during pregnancy is an important indicator for the unborn childs health. Proper nutrition and monitoring of mothers health both during pregnancy and lactation is equally important for newborns health. Deficiencies of nutrients in this critical period can have long-lasting effects. Decreased folic acid intake in the pre-conceptional period has been linked to neural tube defects in the humans. Lack of choline in a mothers diet during pregnancy and lactation may have life-long effects on their child. Studies suggest that choline deficiency in the rat in utero or in the early weeks of life has long term effects on brain functioning, especially memory. A mother needs to gain weight adequately during pregnancy to help nourish her growing baby. Few babies are not fortunate enough to be born with ideal birth weight; some are born as Low Birth Weight babies (LBWs), some are even born premature. There is now increasing evidence that LBW is associated with an increased prevalence of diseases such as diabetes, hypertension, ischemic heart disease and stroke in adult life. The latter is often known as fetal origin of adult diseases. Low birth weight babies and preterm children have different nutritional needs which need to be addressed in an appropriate manner. Premature infants are at greater risk for short and long term complications, including disabilities infections and impediments in growth and mental development. Major advances have occurred in the nutritional support and feeding of premature and immature newborn infants, contributing to the significantly improved chances of survival seen today for even very low birth weight infants in the developed world. Children with special needs often face more challenges and pose more challenges for caregivers at mealtimes than a typically developing child. Some children may require modifications to their diets and mealtime routines. The common areas of nutrition-related concerns for special needs children are texture modifications, appropriate weight gain (too much or too little), and food allergies. These nutritional challenges in special conditions require focused application of concepts of nutrition. Developing innovative nutrition methods in resource limited settings, emphasizing more on the preventive role of nutrition rather than the therapeutic role and addressing the growth and development needs of growing children by providing appropriate nutrition and assessing them at regular intervals is the requirement today. Nutritional care today is emerging over a broad range of pediatric domains such as gastroenterology, surgery, renal, care of disabled children, infectious diseases etc. There is an immense need for taking the steps in the right direction and answering the nutritional needs of the children. We need to address the issues by building capacity and sharing knowledge with stakeholders so as they develop the right perspective to deal with the nutritional needs of the children. This can be addressed by developing academic programmes such as the present programme in the area of Pediatric Nutrition catering to the nutritional requirements of children and developing pool of skilled nutritionists and health care providers who will address the nutritional issues of children. From our study above it must have become evident that there is a defined area of pediatric care that requires nutritional expertise, hence the focus on pediatric nutrition.

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Check Your Progress Exercise 2 1) What do you understand by the term by continuum of care? 2) Enumerate the child survival interventions related to nutrition. 3) Elaborate briefly why the study of pediatric nutrition is gaining importance.

Childhood- Critical Periods of Life Cycle

1.6 LET US SUM UP

In this unit we discussed about the critical period of life viz. pre and perinatal, neonatal, infancy, childhood and adolescence. We learned why these periods are called critical period and the importance of nutrition in various critical phases of life. A review on the neonatal, infants and child mortality have been presented to familiarize with the situation of child health in our country. Further discussion was continued with continuum of care of the children and mother for their healthier future. Under continuum of care, key behaviours and interventions that should be integrated into existing maternal and child health programs to improve newborn health and survival have been discussed. The child survival interventions especially those related to nutrition (which includes both preventive and treatment interventions) was also discussed. In the last section scope and importance of pediatric nutrition was discussed briefly.

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Child Growth, Development and Nutritional Status

1.7 GLOSSARY
Kangaroo mother care Resuscitation Supportive care : : : Type of care of new born by providing direct skin-to-skin contact with mother or father. The act of reviving a person and returning them to consciousness. Services rendered by members of the health professions to improve the patient's comfort and quality of life.

1.8 ANSWERS TO CHECK YOUR PROGRESS EXERCISES

Check Your Progress 1 1) a) Neonatal mortality rate, is the number of deaths during the first 28 completed days of life per 1,000 live births in a given year or period. b) Infant Mortality rate, is the number of deaths before one year of life per 1,000 live births in a given year or period. 2) In majority of the cases, maternal nutritional status decides the fate of the pregnancy outcomes. It is clear by the fact that in developing country like India, most of Low Birth Weight (LBW) and intrauterine growth retardation (IUGR) is caused predominantly by maternal malnutrition, either before conception or during pregnancy. 3) The critical periods in the life cycle start from the time before birth till adolescence. These periods are: Prenatal (the time from conception to birth) Perinatal (immediately before and after birth) Neonatal (birth to 28 days) Infancy (from birth to 12 months of age) Childhood (from about six to eleven years of age) and Adolescence (between 10 and 19 years)

Check Your Progress 2 1) The continuum of care has recently been highlighted as a core principle of programmes for maternal, newborn, and child health, and as a means to reduce the burden of half a million maternal deaths, 4 million neonatal deaths, and 6 million children who die between the ages of 1 month and 5 years. The continuum of care approach promotes care for adolescence/mothers and children from pregnancy to delivery, the immediate postnatal period and childhood, and the newborn child.

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2) The child survival interventions related to nutrition are enlisted herewith: Breastfeeding (including exclusive breastfeeding for the first six months and continued breastfeeding for the next six months). Adequate complementary feeding between six and 24 months. Micronutrient supplementation supplementation. Oral rehydration therapy Immunization like Vitamin A and Zinc

Childhood- Critical Periods of Life Cycle

3) Nutrition has its strongest effect during childhood. Undernutrition jeopardizes childrens growth and development, health and survival. Undernutrition has serious, long-term consequences because it impedes motor, sensory, cognitive, social and emotional development. Recent evidence suggests that several of the major diseases of later life, including coronary heart diseases, hypertension, type 2 diabetes mellitus originate in impaired intra-uterine growth and development. On the other hand childhood obesity is now being considered a major health hazard. Obese children will tend to become obese adults and they would be at a high risk of suffering from diabetes, stroke, liver diseases, infertility, hypertension, arthritis and cancer. So, there is an immense need for taking the steps in the right direction and answering the nutritional needs of the children all through the critical periods and this is the reason why pediatric nutrition is gaining importance.

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