WORLD HEALTH ORGANIZATION R e g i o n a l O f f i c e f o r the B a s t t i l l Mediterranean
m o 0113 January
ww7e
1969
ENGLISH ONLY
mwm ON THE SEMINAR ON THE HEALTH NEEDS OF THE PRE-SCHOOL CHILD K a r a c h i , Pakistan
26 February t o 2 M a r c h 1968
WORLD HEALTH ORGANIZATION REGIONAL OFFICE P'OR THE EASTERN MED-NEAN A L E X A N D R I A
1968
The views expressed in this Report do not necessarily reflect the official policy of the World Health Organization. This document has been irepared by the WHO Regional Office for the Eastern Mediterranean for Governments of Member States in the Region and for thosw who partlclpatea In the Yernlnar.
Participants and Observers who attended the Seminar on the Health Needs of the Pre-School Child held in Karachi, Pakistan, 26 February to 2 March 1968
WHO EMRO
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m o TABLE OF CONTENTS
0113 nage i
I 11
INTRODUCTION.
BASIC DAT 4.. . .. I11 HEALTH AND HEALTH PROELEN3 OF THE PRESCHOOL CHILD.. 1. 2. . . .
Definition......
..
IV
.. .. . . .. ....... ..... ...... .. ... ... Infectious Diseases.. ... ....... .... ....... ...... .. .. 7 . Accidents..... .................................. . 8 . Changing Cultural Patterns. ..................... NUTRITION OF THE Pm-SCHOOL CHILD - PRORI,FJCS AND NEEDS a . Normal Nutrition. .......................... .... 5. 6. '
3 . 4 .
................................ Causes'of Vulnerabilitv.. .... . .. . . . . . .. . . ..... . ... Growth Studies....
.. . . ........ ................. . .... . ..............................
.............................. .......
Modei Health Services for the Pre-School Child.. Malnutrition.. . . .
.
.
. .
.
.
.
~
b.
Nutritional D e f l c i ~ n r l ........................ ~s Measures to Combat Malnutrition -.Recommendations 1 . 2.
c .
Tmmndihte
M~ast~rres.
........................
Long-term Measures.
........................ -
V
MENTAL HEALTH OR THE PRE-SCHOOL CHILD
NEEDS.
........................................ ......
PROBLEMS AND
A.
Introduction.,.. Specific Asnects 1. 2 .
................................
B .
Range of Normality.
............. ..........
Psychological Needs.
....................... ..............
C .
Recommendations 1 . 2 .
Education of Health Workers..
Education of Parents and General Public..,. Preventive Mental Health for Children...... Need for Integration of Services..
3.
4.
. ........
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TABLE OF CONTENTS (Cont'dl -
5 .
Speclallzeo institutions
.................
?age i
19
. 1. ,
6 .
Assessment of Mental Deveionment..
........
1 9 1 9
Magnitude of the Problem of Mental Ueviation . . . . . . . . .
METING THE NEEDS OF THE PRE-SCHOOL CHILD. ,
.......... . ,
Organization of Medical Care for Sick Children.
1 9 1 9 20
2 .
3 . . 4 .. 5. 6. VII
.
.
................... PERSONNEL REQUIREMENTS TO MEET THE NEEDS OF THE PRE-SCHOOL CHILD. .................................. Integration of Services.... . . . , . .
........... Need for Recreation............................ Day-care Centres.. ............................. .. Services of Handican~edChildren.. ............ Admission of ?;lotherswith Children.. . . . .
.
.
.
.
.
.
21
21
.
.
.
.
.
.
22 23
. . .
RECOMMENDATIONS ,' REFEIIRI?iG TO C H A P T ~ VI ~ A N D TDI..
.
23 25
ANNEX A ANNEX 'B '
FINAL LIST OTPARTICIRANTS AND OBSFBVERS
LrST OF WORKING GROUP m
S
ANNEX C ANNEX D ANNEX E . . . .
AGENDO PROGRAMME OF THE SEMINAR LlSli' UF UUCUMYNTS AND BACKGROUND MATERIAL . . . . . . . . . . . . . . . . . .
WHO EMRO
The Seminar on the health needs of pre-schoal ohild in the Eastern Mediterranean Region, sponsored jointly by the World Health Organization Regional Office for the Eastern Mediterranean and the Government of Pakistan, was held at the NurseshTraining Institute, Karachi, from
26 February to 2 March 1968 The purpose of this Senlnar was to convene a number of senior paedlatrlclans, public health aamlnlstrators ane child health experts from the countries of the Eastern Mediterranean Region to review the health problems and health needs of the pre-school chlld m thls Hee;lon, since it is recognized that the children in this age-group represent a numerically important and highly vulnerable part of the regional population which notwithstanding that not always receives sufficient attention.
. E . Kazi Anwarul Haque, Central Minister The Seminar was opened by H of Education, Health, Labour and Soclal Welfare, of the Government of Pakistan, D r .A . H . Taba, Director of the WHO Regional Office for the . K . Hasan, Director-General and Joint Eastern Mediterranean, Brlsadier C Secretary to the Government of Pakistan, and Mr. F.F. Smithwick, UNICEF Representative a.i., Pakistan. The participants came Prom the followi~~g countries: Ethiopia, Iran, '
Iraq, Jordan, Kuwalt, Lebanon, Llnya, PaKlstan, somalla, Sudan, syrian Arab Republic, United Arab Republic, Yemen Arab Republic in the Eastern Mediterranean Region, and from Thailand in the South East Asian Region. During the first plenary session, Dr. Hamid Ali Khan, Professor of Paediatrics, Jinnah Post-Graduate Medical College, Karachi, was elected
. H . Jalloul, Director of Preventive Services, Beirut, and Chairman, Dr. H
Dr. (Mrs.) Lam'an Amin Zaki, Associate Professor of Child Health, Baghdad, Vice-chairman, and Dr. S.F. El Sherbini, Professor of Maternal Child Health, High Institute of Public Health, Alexandria, Rapporteur.
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The provieionnl agenda was adopted as :,reposed. Mention was made of the
fact that the original ?lan had been to include the following items also: a. integration u f MCN ar~.vlces Into general :?ublic weli'are services,
including health services, and b.
nlanning a ~ develonment d of the Health Services for the Pre-school
W i l d within the framework of sooio-economic planning and developmerit of the countries, but that these tonics were thought to be so broad and so im~ortantthat it would be preferable to cjedicate a senarate seminar to them, if gossible by the end of 1,269. All oarticinants had been provided with a set of working ?apers in advance of the Seminar.
A list of these working 3apersis included at the
end of this report (Annex E ) . The participants ricrc cnllc.5 uxmn tu stdtr the doLual pr'ublems and needs
of the child from 1 to
5
in their various countries, to offer possible solutions
to these problcmo, and to make ~-c~u~~ui~erdatlons as to what measures should be
taken to meet the needs. During the first session two introductory papers were read by the WHO Regional Adviser on Maternal and Child Health and the WHO Consultant. It was decided to discuss these papers together with that on the Health and Health ~roblemsof the pre-school child introduced in the second session on the next day.
I1
BASIC DATA
A questlormalre had been sent to the Gifferent Governments of the countries a number of data concerning vital in the Region with the request to ,~rovide statrstlcs and common health 7roblems of the child population under consideration, as well as on public health measures taken and ,?ersonnel trained to combat dlsease and to nromote health in the pre-school child. The pertinent data were used by the WHO consultant and advisers as a basis for their working papers.
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Although not all Governments had been able to return the questlonnalre and although facilities for collecting and ~rocessingthe data were still lacking in some countries, perusal of the questionnaires returned Led to the following basic information: : , from 10.5 to 15 percent of 1 . The children from 1 to 5 years make u the total population. 2.
Crude birth rates vary from 24.4 (~yprus)to 52 p e r t
Jif
4 r ran); most
figures given are between jO and 45 perosnt. j-
3.
Infant morta1it:i varies from 27.5 (Gy3rus) to 152 per 1 0 0 0 live The smaller countries show, on the
born (Ethiopian survey figures).
whole, a lower infant death rata than the larger ones.
. 4 to 4 . Death rates in the age p;roup 1-4, where given, range from 0 around 2 9e.r 5 per 1 000 of the total po?ulation, most. figures . ., .~ , being . ~. .. . ~ . 1.0 0 0 .
5 . The most important causes of $eat21 are unanimously reported to be gastro-intestinal diseases and respiratory infections, often on the basis of underlying malnutrition. Measles also play an important part,
as well as in some countri~j diphtheria and meningococcal meningitis.
I t is interesting to note that accidents both in the homes (poisoning, burns, falls) and traffic accidents, slay an imyortant role already as causes of death (and presumably of morbidity) in many countries of the Region. As far as the questionnaires allow any conclusion on this ~ o i n t ,
neither tubercu1osi.s nor malaria seem to be of much importance in causing mortalitv in this age group in the countries.
6 . Some of the returns show satisfactory standards of immunization of the children from 1 to 4 in relation to smallpox and to poliomyelitis. On the whole, however, the rercentape of children immunized against the various disrasss where such is ~ossible, is rather low and shows a m d e scope for improvement.
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4 1
~"!
4 i l i .
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, a&e 4 7. I n ell coLintric.s or trie iiegion t k i i r i ? n:,pears t o be an a:?,alling f i ~ t u n a t e * , :;omc of t h e r e t u r n s show
l a c k of fem%le MCH workers.
t h a t i n t h e .:>eriod ILjhO t o 1965 s a t i s f a c t o r y :>regress has been made i n t h e t r a i n i n g of more female s t a f f .
8.
A l l r e t u r n s show tP,at i n t h e same yeriod t h e number of attendances
a t both a n t e n a t a l , baby and c h i l d welfare c l i n i c s has increase6 consider'ably. The number, of Ihealth centre:; and MCH c e n t r e s , t o o , show
a g r a t i f y i n g i n c r e a s e aver t h i s ; > e r i o d .
I11 H E A L T H AND H E A L T H TROBLEW OF TWE PRE-SCHOOL CHILD (1-5 YEARS) This s u b j e c t , introc'ucec: by one of t h e
WHO Ternnorsr?~ Advisers, i s of These were:
such a v a s t n a t u r e t h a t i t was agreed t o l i m i t t,he Ciscussions t o t h o s e items t h a t were not being d e a l t with i n another context.
1. The d e f i n i t i o n of t h e age-grou::, under c o n s i d e r a t i o n
The general o7,inion was t h a t , though f o r s t a t i s t i c a l 7urposes (e.g. morbic!ity and m o r t a l i t y s t a t i s t i c s ) one should d e f i n e t h e pre-school child
- (a term thought by some not t o be very a c c u r a t e i n view of the should v i s i t
f a c t t h a t many c h i l d r e n i n t h e Iiegion a s y e t do not go t o school a t a l l and t h a t , mor'eovcr i d e a l l y speaking, even t h e four-year-old some ty:,e
of "school", be it kin6ergarten o r nursery school, t o accluirf
t h e degree of a @ a n t a t i o ntowards o t h e r s neede0 l a t e r on i n l i f e 3
- as
" t h e c h i l d from h i s f i r s t t o h i s f i f t h birthday", t h e d i s c u s s i o n s should not be r e s t r i c t e d t o t h i s age-group e x c l u s i v e l y . The vre-school c h i l d
a s defined above i s a l r e a e y t h e r e s u l t of t h e impact of many exogenous i n f l u e n c e s on h i s g e n e t i c c o n s t i t u t i o n , an6 t h u s cannot be considered a p a r t from his his tor;^ both a s a f o e t u s znc' a s an i n f a n t . of t h e h e a l t h problems which mtlrlc t h i s i-:eriod, a s e.g. Moreover., many
malnutrition,
manifest thernselvc~salready i n t h e second h a l f of t h e f i r s t pear, so t h a t s e p a r a t e d i s c u s s i o n would seem r a t h e r a r t i f i c i a l . O n t h e o t h e r hand,
t h e c o n c e i ~ tof t h e i n f a n t -is t h e c h i l d a s lcng a s it i s nursed by i t s mother t e n d s t o extend t h e l e r i o d of "infancy" i n t h i s Region t o w e l l i n t o t h e second gear of l i f e . Some g a r t i c i ; > a n t s therefor'e advised t o s t a r t using
WHO EMRO
the term "]>re-school child" only after connletion of the second year. However,wbtreas admittedly the moment of weaning is a milestone on the road to independency, there are ma,ny more nilestones, as ability to walk alone, the beginning of speech etc. which may be no less important
to the child, so that this suggestion would tend to introduce a rather artificial dividing line, which would have to be reviewed as soon as the average moment ofveaning would undergo changes on account of changing cultural patterns. Instead of thinking in terms of milestones it might be better to view the development from infant to pre-school child as a nrocess of a gradual loosening of the ties between mother and child. 2. the h i g h vlilnemhility of the c h i l d r a n this age-irroun
The
c a l l s e a nf
These were generally acknowledged to be manifold, First of all, there is the fact that as soon as 'he
child is weanerl, which sometimes is done
rather abruptly instead of gradually, adequate weaning foods are often laobing or, even i f they are available, they are
not. p.r e . p n r ~ din n w n y
suitable for the child. This leads to, not always clinically recognizable, mnlnutrition which influcnccs the body's defence mechanisms in an adverse way. Then, since the weaning process is sometimes a very abrupt one, the nc
child is overcome with a feeling of rejection, thc rnorc co tiimself socially.
hc is in a
period of development wherein he needs constant loving guidance to adjust The feeling notto be loved by his mother creates t.xistill& insecurity and anxiety, which mag lead to either apathy with consequent anorexia or agressive Wehaviour which Lelids Lo widen U l e gap between himself and his mother. all.eady
Tt is evi?ent that this may have its
bad influence on food hablts and food consumption, Thirdly, It Is 1x1 child has t.o go tlhrough a great number of infecthis age-groun . . .. that . . the .... ,. . . . .. tious diseases. The less satisfacLory his nutritional 3t.ate, the less ~
chance there is of a speedy recovc:ry and the groater tke mortality. the other hand tends'eack; nerFod of infect,ionto worsen the child's
On
nutritional state, since he eats less (anorexia) and consumes more (fever) than usual. Thus it becomes increasingly difficult to break -2
the vicious circle malnutrition ; infection
malnutrition.
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-= = -
-
Fourthly, ii is
iii
tilis period that the child comes into closest
3
physical contact with his surrcundings, so that unsanitaryconditions in the home exert their greatest influence. This mav lead to infestation with helminths, to tuberculosis (snittle on the floor) and, again, to gastro-intestinal disturbances due to the habit of exploring the surroundings orally.
By the same token it is in this age-group that
accidents in the home are most frequently ennni~n~ered (poisoning, burns, falls). Finallv, the child is l i n l ? l e t.n
ntreet accidents, since ho can walk Although
-= = -
alone, but does not realize the dangers of the traffic.
~~= ~= --~=-
"= -
~ercentuallytraffic and other ncnidents do not yet play the rolc in causing death in the age group 1-5 in this Hegion they do in technically more developer? cn~~ntries - (where they occupy tkic first rank in both the age g r o w 1-4 and 5-9), they should receive serious consideration.
~. E -
r= 3 -
c -
= -
I
-
3.
Growth studies The need for reliable data on growtn and development of the pre-
-= "! ! !
-. = -
1 -
school child in thio Region, as wall as data was repeatedly emphasized. long ao otandards derived frulli
tlit
diI'J?iculL$ to obtain such
3 = -=
It was generally admitted that, as Lhr local chlld population were lacking,
~= = --
~~-
other standards available (as, for instance, the so-called Boston standards) might be used to judge the y~~uwLh by, knowlng, however, that these standards might have only a limited applicabilitv for other groups than they were derived r~.u111.
~:a ~~-1 --
z ==~
rg
. =
: I ZE! . ~-
~-
Therefore it was agreed that esforts should be made
=
. : m ?
-
to derive local anthropometric staneards from, if possible, longitudinal studies corlcerning healthp children.
--
1 =E ! !
3 -
4.
e --
-
The wag an adequate health service for the pre-school child should be organized The general opinion was that such a service should form an integral
: = ~m
-
-r -
-
part of the ovrrnll maternal and child hcelth o c r v i c c .
Experience
~~~= ~=
teaches, however, that in such a service assistance of the pre-school child t.ends t.n receive less emphasis t h m antenatal, natal and postrlaLa1
..I
3
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cnra, a- well. n c
iilfr,ilt
care. This
is iJue
to vario,us causes, one
of them certainly being the fact that the health workers in the field of MCH,
har<:lgreceive adequate trainin& in the
care of
thc ,?re-school
child, the less so where, as indicate& above, this type of assistance should bc bnced upon an integration of medical, psychological and sociological knowledge. Therefore, a model child welfare centre as be very
dcocribcd by onc of the WIIO advisers, might paramedical personnel, thou611 it cuuld nut
useful for the
training of medical undergraduates and postgraduates, as well as of be
corisideracl
t u ha the
prototy2e of a maternal and child health centre, owing to its lack of inLegratio~i wi L'rl liia
Lel.iial csr'e.
5. Malnutrition was generally admitted to be the main :)roblem of the nre-scnool chi16 ln this Heglon. nesldes to the causes already mentioned Sub 111, 2, this could. be due to lack of ~~roduction of sufficient foodstuffs ?roper I'or this age, their n r o : ) e r storage, transport and distribution, the way the ;arents handle the food and, finallv, the local oustoms of' child Seeding. More information on the discussions concerning this irn,.>ortant topic will be found under IV Nutrition bf 'the Pre-school Child.
--This concerns clearly defined diseases such as measles,
6. Infectious diseases still have their significance as one of the main causes of morbidity and mortality among are-school children. not only the aetiolo,+cally
dinhtheria, whoo2iy cough, meningococcosis, poliomyelitis, typhoid fever and shigellosis, but also, and 7ossibly even to a greater extent, the many forms of resrrirator5g an6 gastro-intestinal infection for which the causal agents remain as yet unknown. Although the latter group of diseasescan only be prevented from becoming harmful bg ensuring adequate nutrition, environmental sanitation, avoidance of overcrowding, and prompt medical treatment, the former could be counteracted effectively by immunizing the child population against diseases like diphtheria, whooping cough, tetanus, i>oliornyelitis, smallpox, tuberculosis and also measles. Ideally,
these immunizations should be given in the first gear of life, with
WHO
m o
reeular re-immunizations during the pre-school period 3s necdcd.
It was st,rongljr felt that more efforts sho~ldbc made in the Region to reach this goal.
7. In view of the ovw-.increasin~ irrqmrtance of accidents as a cause of
----
morbidity, mortality and lift.-lon;;I r a n d i c a j ; ~ , I~or:le.
i L was ralL
that all
health personnel em:>loged in home visiting should he instructed to teach accident y r e v e r i t o l l in Llie
cultural patterns in this 8 . Due attention was given to t,he fact that. . R ~ ~ L Ual,e I L uliaeragolrign fast an;raEa,1
-
cnange. 'Yhis tends to cause
ambivaLence and insecurity in those caring for the ore-school child. Sirlce the chlld +n this age is narticularly liable to nsychotrauma caused bv inconsequent :?mental attitudes, this may have a definite adverse influence on his further mental development.
IV
NUTRITION OF THE PRE-SCHOOL CHILD -
PROBLFbE
A M ) NEEDS
This subject, introduced by one of the WfiO Temporary Advisers, underwent. ~ x t x n s j v ediscussion by a riorkin8-8rou2. Tho roport drawn up by thio
working-,groupwas ' g a i n
fully discussed in nlenary.
The requirements for good nutrition and the health problerns that arise
when these requlrernents are not met, are among the most irnportant of all health considerations of the pre-school child. Even so they make un but one part of the picture and therefore it is important to consider nutritional factors not a s a separate entity, but alongside other factors influencing child health in this age-groun. Here again it should be borne in mind that by the beginning of the period under consideration, i.e. the second year of
life, the pattern of feeding has long ago been decided. Whether or not the baby was going to be breast fed, and what kind of supplementary feeding he was aoing to receive, .had been eecide2 long before his first birthday. in the pre-school child have their origin in infancy. As a consequence, many of the nutritional disorders which manifest themselves
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a.
Normal nutrition The child's requirements for energy metabolism and nutrients
differ in one important respect from those of the adult human being, via in that the child has snecial needs for growth. 1 .
In other words,
his caloric needs consist of the following five components: Basal metabolism, Specific dynamic action of foods (most marked in the case of protein), Caloric loss with the excreta, Allowance for body activity, and Growth.
2 .
3 . 4 . 5 .
During the pre-school neriod there is a padual fall in caloric requirements as expressed per Kg. body weight from about 100 cals. at age one to about 80 at age five. Similarly, the reauirements of reference protein fall from about
1 . 3 gm./Q. ;= e -
to about 0.75 gm./Kg.
during the same period.
(Protein
9 5 7 ) . Requirements, Nutrition Publications, No. 16, FAO, Rome, 1 Considerably more is '<~iow,, about the caloric and protein requirements of young children than concerning those of other factors such as vitamins and minerals, but there is still need for much research in all of these areas. So, for instance, are the r ~ q ~ ~ i r e r n fnr ~ntt sh i n r n i n ~ ,
riboflavin and niacin lipked with caloric requirements, but the recommended intake for vitamin A 2 related t ? the quotient: increment in
body weight/total body weight. (Cf. FA0 Nutrition Meetings Report Series No. Ill, Homc,
1 3 6 7 ) . in diffarent countries and among different
Just how these various :-equirements are rnet will depend largely upon the dietary pattern ;revailil.r:-,rvali
cultural groups, and to some extmt u2on the age of the child concerned. During the second gear of lifc tht. ~lizt s110uld ideally consist chiefly
of milk, bread and other cereals, vegetables, fruit juices and cooked fruits, meat, fish a r i d cghs. -
The quanliLy of i::ilk should be a r o u d
4
a
1 pint (567 cc) a day providing at the same time a properly balanced
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diet of mixec' food to t : i e child.
S1:auld
it not b e gossible to There should be no
provide milk a well balanced diet can nevertheless be feasible if other food nrotein ,sroducts are available. attemnt to staneardize the child's intake, rs long as hc is healthy; the appetite is usually feeds himself. 5
satisfactor:y guide, ~articularlyif he
8 : ;the time the child is eighteen months old, finely
chopped or mashed foods can be substituted for the strained foods he needs in infancy. With increasing aEe considerable latitude can be allowed in the child's diet. Many disturbances, often attributed to food, find
their real cause in other factorVsin the child's life, in particular organic Pisease and/or ;>syehologicaldisorders. h . .
Nutritional deficiencies Ey far the most ~revalentform of malnutrition in the pre-school
ohild is 3rotcin-cnloric malnutritiun. mixed forms wkiic1i
T h i s may take a
va~,iely of
clinical fopms presenting a spectrum of disease including marasmus, l c w a s h i o l r o r and irlay
b e cblleci
mar'asmic Irwashlorltor.
Considering the Region as a whole, marasmus is the most prevalent form. Frequentl:! a~su(:i?iLe(l with 7Yotein-Calori~malnutrition, but
considerably varying in incidence from country to country, are the erfecLs of vl~arniriNelTciencies, especially xerophtalmia due to vitamin A deficiency, and mineral deficiencies, especially those due Lo lack of iron a n Z l unbalanced of electrolytes.
Also, rickets is not
uncommon in the growing child. Houghly speaking, malnutrition in the pre-school child is the result of inadequate dietary intake, aggravated by infections and inr'estations. Artificial feeding is esnecially riangerous because of the mother's lack of knowledge of correct feeding techniques. This leads to contamination of the food. offered and to incorrect composition of -this food. Faiiure to supplement the milk diet adequately at a The present trend to abandon time when milk alone becomes insufficient to provide all the nutrients required is another contributing factor.
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EM/MCH/78 rage 11
breast feeilin-, r..?.?tevcr its cn~lse,is nutritional state of the child.
traiight
with danger for the
The cl ini oal rnanift.st.ations of the severe forms o f malnutrition
in the pre-school are well-known. However, subclinical forms r~sultingin retarclod growth and dcvclopmcn+ arc much morc widcspread than the severe forms and less easy to detect. They occur much more frequently than is gcncrallg rccognizec?. T h e y may hamper the child's mental development and lead to, for example, blindness. 0 .
Moaaurce to combat malnutrition - recommendations These may be divided into: 1 . ImmeBiate measures,
2 . Long-term measures. 1 .
Imnlediate measures Under this heading are considerecithose measures that appear
to nave a high likelihood of effectivity but at tne same time are
relatively easy to implement, in view of the existing facilities. The following are recommended: a . Governments as well as the general public should be made aware by ev'ery suitable means of the size and urgency of the oroblem. b.
Studies should be made to obtain more information on feeding practices and available foodstuffs, in order to
be able to make recom?lendations which are of practical value in the given circumstances. c . Every effort should be made to promote better understanding of basic and applied nutrition science by medical and paramedical personnel. d.
Education of the mothers in the ways of composing and preparing the necessary food for their children should play a major ?art in health education. This should be carried out at various levels, through personal contact,
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group instruction, and by mass media.
MCH centres
c ! : role in this respect. should be taught to nlag a k Their :,ersonncl shouli! be intnicted in the earls detection of minor signs of malnutrition an2 in its handling. e. a c ! e It was aeain em.shasized that a start should be m with comsilation of data on growth an6 d e v ~nprnent., l 50th physical and mental, leading to construction of standards for the different countries of the Region. . . Such data are indispensable if one wants to detect tho
eni-l.iest sians of malnutrition in ilopulation
groups. 2
Long-term measures Under this heading are brought together those measures the
implementation whereof involves the un-~radingof the whole community in socio-economic as well as in educational respect and therefore asks for coordination of the various services employed in nromotinf: the common weal. The measures indicated were the following: a . Develonment schemes aiming at increasim food qroduction and improving the quality of the basic diet should be initiated. b.
In view of the close relationship between poverty and severe malnutrition in the pre-school child, s u h s t . a n t i a 1 imerovement can only bc exaected when the purchasing power of the family is improvrd.
c .
In many laces the basic diet for the adult ponulation is w e l ~ l h n l a n w r l , and here tho emphasis should be placed
on nutrition education.
However, in those areas where
the basic diet is deficient, especially in respect to
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proteins of high quality, the introduction of specially processed food mixtures for the (weanling and the) pre-school child is recommended. ble foodstuffs. d . In certain rural and urban low-income groups there may exist a need for the introduction of supplementarjr feeding nrograrnmes. Wherever such programmesare contem>lated, they should be geared to the local resources and be carefully planned, supervised, and integrated wikh the exist in^ health and social services concerned with family and child welfare, in particular maternal and cl~ildhea5th services, day-care centres, and agricultural and home economics extension programmes. Since ronAit,ions of living and therefore nutritional
Such food
mixtures should preferably consist of locally availa-
shortages tend to change, periodic evaluation of any applied nutrition proEramrne is essential. e . Other mea;urcr: such as family planning, immunization progrnmmce and oontrol of enclernic disease will help to improve the ni~tritionalstatus of the pre-school child. f .
Coordination of all thc cbove-mentioned activities should be implemented by the Governments concerned to ensure the maximum use of available rqnourccs.
V .
MENTAL HEALTH OF THE PRI3-%"::30TA
' YCLD
-
L?OELI,NS AAN NEEDS
This topic, like the preceeding: was first discussed by a workinggroup which drew up a set of state~e~its and recammendations. on the relationship between nutrjtion and mental health. Following this, the subject was disuussed in pl.'znary session, with special emphasis
EM/MCH/78 page 14
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A.
Introeuction In the period between one and f i v e years of zge the child is
actively enp;aged in building up his personality an8 is ranidt:llr progressing in mental developaent. It is r yeriod of great plasticity,
but also of great liability to be influencc2 bg undesirable and untoward factors. It is of importance tc note that the behavioural
c'evelopment of the ?re-school child 3,nssee through varintis critical stages. Though the majority pass through these stages unharmed, some
are unable to coJe with the many stresses cnnf'rontin~them in daily life which leads to retarded and aberrant development with, possibly, lasting sequelae. Whether or not a chi12 \*ill p a s s through theae stages without showing any sign of abnormality, depends not only on the type, magnitude and c"uration nf stress also on his constitutional make-up. Thus the ultimate uersonality is the proc'uct o f the intal-acLiu~~ between biological, :hysical, psychological and cultural factors in his environment on other. t,h+= one
he io
oubjccted to,
lruL
hand, and his genetic culiaLlLutlon on tnc
B. S~ecificAspects In order to understan6 better the various aspects of the child's the following points slluuld be taken lnto consideramental r'ev~~opment
tion: 1.
R a n ~ fof normality
::evelL;~.lr.cnt i f Both in t,he intellectual and in the !~eh.cvir:ural child there cxiats a wide 1.a11ge or normality. Persons dealing with the child should be made aware o f t h i e f a c t * since otherwise thcy rnay either tilake
Cemands on an entirely normal child of a cannot answer since he happens to
given age which that child dcvelup
sluwel. Llm11 average, or thev may wrongly susnect him to
be mentally retarded, with consequent feelings of anxiety, guilt, disa!>poi~iLirirrit or frustration. Both would. lead to a false neda-
gogic approach, with consequent damage to the child's personality.
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In his emotional needs and exqressions the child also shows a wide range of variations, which, however, have a tendency to change both with increasing age and with experience.
2,
Psychological needs
To describe the psychological needs of the ore-school child step by step would be outside the scope of this report. However, it was agreed -that these needs could be summarized by staCiog that the chilA needs the constant understanding, respect, love and support of those concerned with his upbringing. Moreover,
he should be offered sufficient opportunities for play, alone and with others, since in his play he has a chance not only to explore his environment, but also to express himself better than by any other means, which releases tension and enhances his
feelings of accomplishment. In connection with the above the isrow laid sgecial emphasis on: a. The necessity to interyret rightly the various aspects of child behaviour, inclueing ostensible abnormalities such as negativistic n t , t , i t , l ~ ? ~ hnt.wwn n +.he second and the fourth year of life. b. The fact that, it. i s vpry
difficult, if not impossible,
to sta.te with the help of so-called "batteries of nsychnlngi~caltests" whether or abnormal. a fiiven child is normal
A better criterion for normalcy was found
to bo satisfaotory socinl adjuotmcnt.
c.
In many communities in this Region there still exist misconceptions as to the nature of certain forms of mamLa1
aberrations.
Mental retardation, for instance is some.. .
times identified with madness and approached as s u c h ,
epilepsy is thought to he due to oossession by demons, ctc. These miscunca!,tiuils aiiuulcl l i e
arrienable to neal'th
education, with consequent better outlook for the happiness uf tilt?
dfrected child.
EM/McH/'L~ page 16
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greatly influence the child's behaviour. L 1
Consequently,
the child should never be looked at as a seoarate entity, but projected against the background of his family. e. Parents should be warned against an either Doo rigid or too permissive approach in the child. upbringing of
' h e
:I
f.
No m i l P-of-t.humb
psycholngical formulae can be pres-
cribed for every nossible variation in the child's behaviour. However, the ~eneralrule should be that the child be approached affectionately, wisely and consistantly. Every cffort ohould bc made to make the child confide in his elders and to make him feel ECCUFC.
g .
The child never can attain social adjustment unless he ia
being cunstantlg
stii~~ulatcc by l his
a~lvlru~ui~e~lL. Such
stimulation, however, should contain positive elements and avuid nabdllvt!
o r l e s .
This r i u t s due responslblllty
upon everyone who comes in contact with the child, both wLLhi11 thefamlly and outslde, as in kindergartens, nurseries, crhches, and actually in the society at large. h . The stronger the family tles and the better the housing conc?itions, the more chancethe child stands to grow up n c i to adjust himself'socially. Therefore every normally a effort should be undertaken to strengthen the family ties and to improve housing conditione.
C .
Recommendations In view ef the above the following recommendations were made: 1. Education of health workers Health workers (physicians, dentists, public health workers, public health nurses, midwives, health educators, sanitarians, health vfsitors, etc.) who, by the nature of their work, are in
WHO
mo
oontact with children and their fnmllles, should receive adequate education and training in the field of mental health,especially in the fundamental principles of child development, in the emotional needs of the child and in the psychological problems arisine from maladjustment. Although the scope and magnitude of the These are: problems vary from culture to culturc, certain featuses common to all should be recognized. a. The age at w11ich the child is subjected to ntrcoo
i e important for the ultimate effects. b .
The suucepLlblliLy Lu aiino~~ilal ewstional reaction3 is greater at the beginning than at the end of the perlod under co~~ulda~aLiun.
c .
Prolonged stress, be it of a physical, Psychological
or soclal nature, tends t m 1nter.ft.r-e with normal development. These facts have in particular been ascertained In the fields of nutritlonal and of maternal deprivation. d . Since the pre-school child cannot verbalize his inner conflicts and emotional tensions, these will be reflected in his behaviour; it should be realized that the child reacts to stresses as a unity, and therefore, in order to understand abnormal behaviour, the child's emotional and social milieu should be taken into account. Instruction of the health workers in the psjrchologlcal problems the child has to cope with will enable them in early detection of deviations, simple management. .of minor ones, correct where needed and . ~ . .. ..... ~..- - .. referral . . .-.... . . follow-up of.hhe chl-ldathome or in the community. ~ ~
-,
!
E M M /m a : ;
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page
18
2 .
Education of the parents and thc general nublic One of the best approaches to prevent mental and emotional
disturbances would appear to be to teach the parents and the general public the fundamentals of child development in simple and easily understandable language. This couli! be done by
personal interviews, by composing instructive leaflets, an? by mass media (women's magazines, radio, television). Misconceotions
and faulty attitudes existing in the community should be corrected as far as possible. In doing so, a sympathetic atti-
tude has more chsnoe of succeeding than pedant,ry. Since the famil!,, is the proper institution for.the training of the pre-school child, prcapective parents should be prepared for this task in their )youth, for instance by dedicating snecial hours to this subject in the highest forms of primary, anrl certainly of secondary,school. ,
It should be emphasized that gr~wingu l ? in an atmosphere of religious faith enhances the child's tolerance towarc: ?svcholop;ical stresses. To this aspect of f-zmiiji and community life due attention should be given.
3.
Preventive mental health for ck,ildren M o r t crror'ls shuulcl be rnac~e 111 the rlelcl of p r e v e r i L L v e
mental h t . l t h a.
for chileren.
Such activitits woule imply:
recrultrnent of nersomel quallfleci In mental health work; 1-rovision of facilities such as ahild guidance clinics; making use of exiscant facilities a n r l staff for referral and consultation;
b. C.
c'.
InCluSlon of rnental health activities as an essential element in the overall r~ubiichealth programme.
4.
Neer! for integration of 'various services dealing with mental aberrations in young children To make o7,timal use of the existing facilities coopprat,inn
between the various agencies dealing with mentally aberrant children
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5.
Sgecial institutions Establishment of specialize< institutions, depeneing upon
the availability of resources and pr'iority needs, is recommended for dealing with special categories of mental and emotional disturbances. Such institutions should, whenever possible, be
located in close proximity to the families concerned. They should be kept reasonably small, be well staffed, and adapted to the needs of the children and to the cultural pattern to which these children belong.
6.
In the assessment of the chi1c"s development and behaviour, are of
tests developed in variouc countries of the Region, questionable value. nee$&,
They should be carefilly studied and, where
new or at least modified tests, adju~tcdto the social
pattern, should be devised.
7.
At present the magnitude of the problem of abnormal mental
develo3ment and behaviour among children in this Region can only
be guessed at.
Also, the best way of handling this problem needs
much further study. The results of surveys ma?e in this field should be translated into an intelligible and realistic programme which could be immediately put to the test in actual practice. VI
MEETING THE NEEDS OF THE I'RE-SCHOOL CHILO This topic was introduced by one r'f
the WHO
Ternlporarg Advisers and
discussed in alenary session. The c~iscussions were centered mainly around the following itcms:
1 .
Organization of medical care for sick children It was
generally agrccd that whcncvcr 7ossible the child should This would avoid the dangers of cross infection the
be treated at home.
in uver-crowded hospital wards, be gener~lly less uustly
chnncco of hoepitalism resulting Treatment at homc can
from seraration from the mother and other relatives; also, it would L i i m
llospital care.
in principle be performed in two ways, the one being on an ambulatory
EM#McH/~~ page 20
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b a s i s , whereby t h e child i s brought t o t h e n e a r e s t c l i n i c o r h e a l t h centre whenever needed, t h e o t h e r by <?omicilizrynursing. The l a t t e r ,
more t h a n t h e f o r m e r , c f f e r s t h e opportunit). not only t o become acquaintecl with home conc'itions, but a l s o t o e f f e c t changes t o t h e b e t t e r by i n s t r u c t i n g t h e mother how t o nurse h e r . c h i l d , how t o prepare t h e food, how t o keep t h e house and i t s surrounc?ings clean, etc. However, it l,>dts a g r e a t c'emand on t h e s t a f f , an<) i s hardly
f e a s i b l e i n those communities where it i s not y e t acce]?ted f o r unaccompanied female workers t o v i s i t t h e yoorer q u a r t e r s of t h e community. .. ... . . .. .. . . .~. . . . . ..
2.
Asmission of t.he mnt.hern w i t . h t h e children
O n -issue
t h e r e e x i s t e d a marked d i f f e r e n c e of opinion among
+.he p a r t i c i ~ a n t s . Some meant th2.t suoh p r a c t i c c not only has g r e a t
advantages i n t h a t t h e c h i l d i s guar,anteed t h e supy)ort.of h i s mother am3 does not f e e l abandoned, t h a t t h e mother can be taught t h e
p r i n c i p l e s of child n u r s i r q . a n d o'f + & i o n a i hygiene, anc' t h a t it r e l i e v e s t h e nursing ~ t a f ffrom oome of i t s chores, but t h a t i t i s sirnnly i n d i s p e n s b l e i n view of t h e shortage of nurses an6 nurse-aids. Othcrs, however, f e l t t h a t , although the above i s aGrnlttedly t r u e , it tends t o put a g r e a t s t r a i n on t h e mother who, e s g e c i a l l y when t h e child has t u ! , e tluspiLaliee? f o r a somewhat longer period (e.$. i n case of tuberculous m e n i n g i t i s ) , begins t o worry about her The l a t t e r a r e only then taken care Since,
husbanl! and tier oLher' c h i l l r e n .
o f , i f t h e so-called extensed family system s t i l l a r e v a i l s .
wiLh the rapit changes i n family p a t t e r n , t h i s ty?e of family tends t o disappear, t h i s i n i g r , t . make. it.d i f f i c u l t i n .the n e a r f u t u r e .t o admit Lhe mothers t o h o s p i t a l with t h e i r child a s a r u l e .
Moreover, some
g a r t i c l o a n t s were of t h e opinion t h a t admission of t h e mothers i n t r o a w e d an uncontrollable source of i n f e c t i o n . F i n a l l y it was pointed out t h a t nowhere i n t h e Region f a c i l i t i e s e x i s t e d t o bear t h e c o s t s of t h e mother's s t a y i n h o s p i t a l which may make i t i m p r a c t i c a b l e i n some cases.
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EIM/MCH/~~ page 21
Anyway, it was generally agreed that where such practice exists and is likely to remain the normal course of events in the near future, provisions should be made for the mother's stay in hospital, such as toilets, washrooms and cooking facilities.
3 .
Recreation for the nre-school child Recreation was generally recognize.', to be one of the basic Facilities for healthlg recreation are, however,
needs of chile.
sometimes sorely lacking. They should consist of clean and airy wlavnrounds, sheltered off from traffic and in the immediate vicinity of the housing complexes. They should. provide the child with the In town planning these .,,
possibility of exercising his muscles and increasing his motor skill, without introducing $anger of falls etc. needs should be taken into consideration. .. .. ~
4 .
Day-care centres Much attention was given to the potential use of day-care centres.
Such centres seem to offer good facilities for regular medical inspection of the ohild, includiw eye care and. dental care, performing i m i z a t i o n s , introducing supplementary feeZing programmes, etc. Moreover, they he19 the chi12 to adapt hirnsclf to other persons, children or adults, and thus assist grnatly in the maturation of behaviour. Their only ciisadvantage ~ e e m ato be
that they are n real focuo
of communicable disease. This might make them less desirable for children with a constitutional proneness for, for instance, respiratory disease, but on the whole, every cllild has to go through the various ctiildhood diseases, a r i d L1ier.eror.e he car1 beLLor, do so i r i arl errnlro~u~lenL where there exist ~ossibilitiesfor prompt recognition and treatment.
In oraer to runctlon rlghtly, clay-care centres should be wellstaffed, so that sufficient attention can be given to the children. Only the quantity, also the quality of the staff is important, whlch asks for training of nursery nurses or nursery school teachers. Not
EWMcW78 page 22
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The next goint was that efforts shouli! be made to ensure wherever ~ossiblc,continuity of service between c'ay-care centre and school hislth sarvice. It was, of course, realizcd that however grest their advantages, it woull be impossible to provide: the country with a number of daycare centres sufficient for all pre-school chilcl.ren. Still, if the mother has to go out working a n ( ' there are no other relatives to look after the child, some sort of day-care is wanted. In this connection, instances were given where a simple type Such possibilities should be of Cay-care was nrovidecl by women from the neighbourhood either on a voluntary basis or on token payment.
actively looked for by the health workers icealing with the families.
5.
Services for hallciicaaped chil?.ren With the exception of isolated and thinly scattered rehabilitation the i~achinym , edical c e n t r e s ,
effort b ! y voluntar:r societies and some of nre-school child are st,ill Actually, in view
it may be saici that the needs of the physically and mentally disabled 11nrne'
not o n l y t h r o u ~ h o u tt h e d c v c l o p i n g
areas of the world, but even in many of the Seveloped countries. nf t . h ~ i n c r e a s i n g nurnber of c h i l d r c n whorec l i v e o
are saved from severe illnesses as meningitis and encephalitis, as well a s f r o m heavy t r a f f i c s o o i d c n t c , h a n d i c n 7 p i n g c u n d i t i o n s i n i ~ c e -
school chil+.ren constitute an increasing rather than a diminishing :>rohlem. The s u c c e s s of r c h 2 l i i l i t a t i o n io nlainly i1agini:rnt
upurl
tlal.1~
case tl.etection. Rehabilitation of the ?re-school child should as far a s n o s s i b l e be c s r r i c d o u t i n h i s o w n hoiliu,
ir-islituliorisbeing used as
a last resort. ncccooary,
Specialize(', institutions are not only not always l r i that they Drove to the Therefore, efforts should be mack to
t h e y even inny have h a ~ . i l i r u lerrects
chile! that he is a cri?nle. wherever 2ossible. recent yeal's.
integrate han2ica:)j~e~ u l :l i l t i r ' t r l with healthy ones in
cay-care centres,
Such practice has been greatly encouraged in
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6 .
Integration of services meeting pre-school child
B e
health needs of the
It was generally felt that the various types of care for the pre-school chilC shoul<l be considereil as parts of a whole, so that making :)lans for this purpose,should not be left to separate agencies, but should be the task of the cornmunit:., whether city, rlistrict, province, or country. i ' l a n s and needs. should be adapted to local circumstances If such integral planning were not undertaken, many
chilrlren might fail to benefit from the facilities to be created. (Cf. ECAFE/UNICEF Conference for Chilaren and Youth in National Planning, Bangkok, 1966). In order to reach this stage of integration, the authorities, educationists, medical and naramedical personnel, social welfare workers, and, actually, the general public should receive more insight in the needs of the nre-school child..
VII PERSONNEL REQUIREMENTS TO MEET THE NEEDS OF THE PRE-SCHOOL CHILD This subject, the last one to be discussed, was again introduced by one of the WHO Terniiorary Advisers. The disc.issions were centered maknly around the qualitztive aspects of the qroblem, although from the quantitative side there is a great shortage especially of female personnel. The following points were raise?:
1 .
It is essential that all health and social welfare nersonnel Such
should know more about the chilc'. in the age-grou:~concerned.
knowledge should not be of an exclusivel!~general nature, but the local cultural setting in which the child has to live should also receive due attention. However, nertinent information concernina the Therefore, efforts should be made cultural pattern is often lacking. t o collect i ~ c h information,
t o i n t , r g r a t , n i t . i n t . n t h e t . e a n h i n g programme
for health ~ersonnel,and, for the training of personnel of lower academic standins, to
translate it into the local 1ane;uage.
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2 .
Lately m c h new knowledge has been ~ccumulatclconcerning Such knowledge ought to be incorporated
the nre-school child.
into the textiiooks for physicians, nurses and other health personnel. It was felt, however, that in some countries the experts in this field were insufficiently consulted, when textbooks were revised or new ones nlanned.
3.
It was repeatesly emnhasized that both in instructing health Such intruction should, of course, he carefully r~lanned
workers ane the general public, more use could be made of the various mass media. and supervised.
4 .
Some participants were of the opinion that in the nresent
'training of health personnel too much emphasis was placed upon the technical aspects of their future jobs, and that not sufficient attention was paid to the nractical aspects of approaching the ~owulation. Therefore, the ways an? means nf n?prnnchinp: +he prthl.io should be taught, vreferably during neriods of in-service training.
5 .
One of the reasnns for
+he
shortage of health personnel was felt
to be that health workers, especially those working in remote areas, dn not. always receive due recoanition. Every effort ohould bc mndc to up-grade the status of the health personnel in the eyes of the general public.
6.
In such areas where there is still a great shortage of qualified be
midwives, eimplc training of indigenouo midwives should according to some.
cuntinued,
This certainly would not lea6 to an ideal situation,
but it would at l e i l o t have the double adval-itlrga u f p~~evuillirlg Ltie wur.sL
c'elivery practices and of establishing better relations between qualified and unqualificd miclwives.
7 .
In principle, health workers should be taught to act as a team, seyaraLely. Therefore, teaching should include some aspects
and 11uL
of the work and the problems of other categories of health workers.
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Moreover, the activities of a health team should be closely coordinatee with those of other workers in the area, such as the home economics, extension worker, agricultural extension worker, and community development worker, this with the aimof improving the quality of the services rendere2.
8 .
In oreer to establish and ensure good communications
between the various members of a team ofhealth workers, it is necessary to hold regular meetings where the local supervisor of the team should be >resent.
9 .
The training of the future doctor and nurse was generally Therefore,
feltto lack emphasis on the preventive and social aspects of paediatrics as well as on public health as a whole. it was advocated that these aspects should receive more attention both in the lecture room and In field practice. 1 0 . It was generally felt that, if too many different categories
of health and social workers were engaged in home visiting, this rnixht lead to confusion on the h art of the child's mother. approached by only one person. There-
fore it was thou~htbetter to have the mother in principle be Obviously, such a person should Specialists then be trained to become a multi-purpose worker, with at least some knnwledge concerning related spheres of action. in other fields than the health worker's own s;?oulG preferably convey their advice a n d transmit ihni~rtechniqllns t,hrough the rmllti-purpose
worker. The discussion of the subjects " ~ e e t i n the ~ Needs of the
Pre-school Chile" and "Personnel Requirements to meet the NeeBs of thc Prc-ochool child" lad to thc following rcoornmen3ations: RECOMMENDATIONS 1 .
The health needs of the pre-school child still rcceive relatively
little attention in health policy, health planning, health services, au2 in the contellt u f tll~teacliing programmes for health peroonnel,
in particular in the medical curriculum; it is, therefore, recommended
EP~McH/~~ page 26
WHO EMRO
that this subject
be
given duo consideration by heath nlanners,
health administrators a n c : by those in charge of teaching various ciitcgorios of hcalth worlicrc in all countries of thc Rcgion.
2 .
In order to reach the goals set above, more ought to be
known concerning thc nccds of the prc-school child in the Region, with emphasis on his functioning in the context of his sociocultural environment. It iri
thcrcforc, rccommcndcd that ficld
studies be undertaken to collect and assemble the necessary data, both as regard3 physics1 and. mental growth and. development. To
set stanciards of normalcy, onysical growth studies, as well as studies in paychumutor clevelopme~nt , ahoulcl, wlierevcr possible longitudinally, be conducted, using groups of healthy pre-school uiiilUr'e11.
3.
The knowledge thus obtained should be ma6e available to all
caLegor.iea or tiealLh wor.kar.s ard to Lhe gerier.81 public.
IL ia,
therefore, recommended that such knowledge be published, not only in scientific pavers, but that it also be rnade avalla3le in
simplified form and in the local language(s).
Such knowledge
should be exchanged between t r l e countries of the neglon.
4,
a.
In clealing with the health needs of the pre-school child
the broad environmental appr'oach, Breaking the vicious circle ofpoverty, disease, ignorance and malnutrition affecting the child and Its Samily, requires s:secial emnhasis, it is,
therefore, recommended that brcad spectr~unj!rogrammes be desippec! to strenghen S a r n i 1 . y life, to improve housing conditions anr' basic preventive services (eirectee both towards the environment and towarils the individual), and that 0p:)ortunities be created for em~loymentand economic security. b . In town planning facilities for play and recreational
activities of pre-school children should be provided; of equal imortance is the Tornotion of safety measures in home an? envircnment to prevent t l l c occurrence of accirk-nts,
WHO EMRO
5 .
There is need to improve the quality of health care while
trying to meet the quantitative health needs in the pre-school age period. This relates to personnel, to physical facilities It is, therefore,
and to the methods of delivering health care. recommended that: a .
Both minimal attainable anc? optimal standards be
established in the countries of the Region, in accordance with local resources; b .
Health administrators and those con~ernedwith the
teaching of health personnel cooperate in defining the necessary criteria for t;.~ acsessment of these needs; c . Attempts be made to inculcate and impose the standarcs
indicated above by licensinn, continuous supervision, and grants-in-aid.
6.
In health and nutrition education given to mothers and other
members of the family, the role of the multi-purpose health worker should be emphasined, since ailvice given hy too many clifferent persons tends to lead to confusion. ?or this end the public health
nurse, the midwife or the health visitor are the most suitable, lvlt if these are not available other welfare workers (nutritionists, social workers, homs aoonomios and agricultural extension workers) should take over the role of multi-purpose worker. In princi>le,
all field workers should try to impact th2 cseontials of their advice to the multi-purpose worker, who, in his turn, should transmit this to the mothers and other members of the chi1i"o family.
W H O EMRO
EM/MCH/~~ A N N E X A ImGe i
FINAL LIST O F P A F U G W S AIW OBSERVERS FARTICII'ANTS
EMRO
ETHIOPIA
-
D r , :'iit;,os liaila; Lcc-hirer i n i'cctlintrics I:nilc S e l i a s i i I U n i v e r s i t y kdilis --.-Ababa M i s s Abeb-I Gobezio
- --" IFiAN
C h e f Notritionist C h i l d r e n ' s i g u t r i t i o n Unit K i n i s t r y of ruolic Health A C i i s Abaha
1 , P..
--
Gliarib ' m f e s s o r of f ' a e d i a t r i c s F?cnlt.. cf Merlicine Univeu.sit,y o f Teheran Tcherzn
C r , Hassan Ahari , ' r o f e s s o r of P a e d i a t r i c s F';1~ill t y of Medicine Univer sit:.. of Teheran TeherLn ~-"----
--
Dr. A. .. 1iahimzsP.egan . De.;ut:: D i r e c t o r ;bt,srn~il an(: C h i 1 d H e a l t h D i v i s i o n Ministry of Public Health Teherm
Dr, Abbas Emami
I R A Q
ChTel', Iviatern-1 and Chile? H e a l t h ECiiuzeatnn P r o v i n c e apLwa z Dr. 5 . 1 . R1-Sharbati Medical O f f i c e r i n Maternal an2 C h i l d H e a l t h D i r e c t o r y M i n i s t r y of H e a l t h Baghdad
---
EM/MCH/78 ANNEX A nagc ii
WHO EMRO
PARTICIPANT3 (cunt'~) . . ..
IRAQ
Dr. Sezdoon Al-Tikriti Assistant Dean
College of Medicine University of Baghdad Bagtlclac?
Dr. L.m'an Amin Laki Associate Professor of Child Health Baghdad. College of Medicine University of Baghdad Ba&ds.d JORDAN
Dr. Toufik Karadshy
KUWAIT
Technical Director Ministry of Hf;alth Amman Dr. Mohamec' Ilhamy AhmaZ Assistant Senior Health Officer Preventive Health Department Ministry of i'ublic Health Kuwait
-
Ur. ~ . n .~alloul Director cf J'rcventive Health Services Ministry of Public He?lti; Beirut Dr. (Mrs.) Sania Laeeli Director Mctcrnal and Child Hc~lthCentre S o & - tl-Giom~ Tripoli PAKISTAN
Dr. Hamid Ali Khan Professor of Paecliatries Jinneh Post-Graduate Medical Centre Karachi
EMJMcH/~~ ANNEX A page iv P A R T I c I P A ~(Cont ' 2 )
WHO &MR0
..
,
.
UNITFS AMB E3PUBLIC
---
Dr. Plef -is?.E-s.sseir: Iss8 Director, Maternity and Child Welfare D* iartrnent Ministry of Fuhlic Hezltn Caii'o Dr. P.F. Skerbini Trofc:ssor of Maternal and Chili: '~ealth High Institute of Public Health University of' Alexandria klexz~~drie.
Dr. S.4. Tzg El Din Province of Health Ministrv of Wblic Health Fa~roun 1
YEMEN ARAB REPUBLIC
SEAR0 THAILAND
1 1 r . A b r u l Hahaman El Bhdrie Medical Dietician Ministry of Health Sana 'a
Dr. P . Vichitbandha Instructor, Paediatric Department SirireJ Medical College Bawkok
COUNTRY OBSERVEiiS LIBYA b p s . Y , Ab~elnour
Nurse Tutor Maternal ane Child Health Centre Souk-ti-Giouma Tri:,oli
Dr. Ali Nawar, Khan De-uty Director-General of Health Govcrnaent of Pakistan Islamabad
WHO EM90
EM/McH/~~ ANNEX A a g e iii
PARTICIPANTS (cont ' i') PAKISTAN
Dr. (PIX'S. ) Sac!iqa Sano Agha Dt::xlt:r A s s i s t a n t Director-General o f Heelth (MCH) H e l l t h Division i i i t of Hcalth anc? S o c i a l Welfare 1sla1x;:haL
7
D r . K?.hi'uzul Iiuq Chowdl?ur!i Associate l r o f e s s o r of P a e d i a t r i c s S i r S n l i m m i i l l a h Medical College Dacca Dr. ( M r s . ) N.H." Khan Section Officer, MCH Health De-artment Oovcrnrnont of W e s t Paki nt.an
Lahore SOMALIA
D r . Mohamec! A l i Nur Meiiical O f f i c e r (i'aediatrics) Ministry of Health and Labour Mogatlishu Dr. 3.A.R. Ali Tnha paeciiatrician Medani,Hospital Medarii N a b i h Ghabra Medical Doctor c h i l d r e n ' s De~artrnent. ..... ~. Dnrnilsrlls General Hospital Ministry of Health Damascus
S U D A N
SLTLIAN
ARAB REPUBLIC
.
UNITED ARAB REPUBLIC
-
Professor M. Diwani president of t h e Egg2tian P a e d i a t r i c Association Cairo
WHO EMRO
EN/McH/~~ ANNEX A ;,age
v
COUWRY OBSERVERS (Cont' d ) . .
.......
~
PAKISTAN
D r . Subhan Chaudari Chief of Health Section Planning Division Ministry of Health -Karachi
Dr. I d . Habihur Rahman C 1 i n i : : i : : n Leader Directorate of Nutrition Research Government of Pakistan Islamabad Mrs. A. Gani
Senior Community Develo.?r.ient Officer Director~teGeneral of Social Welfare Ki-rwhi
Mr. S.A.M. Hashimi Re~ionalChild Welfare Officer Directorate General of Social Welfare K irachi Dr. A.H. Haqqnni Associate Pl~ysician(paediatrics) Jinnah Post-Graduate Medical Centre Karachi
P
3tgu~ Akhtar Suleman Presic!ent of Pakistan Council for ChjlC Welfare Karachi Cr. (Mrs. ) R. J. Flahinltoola Associate Physician (paediatrics) . J i n n n h Post,-Gra(:uate Medical Centre Karachi
UNITEX NATIONS CHILDREN'S FUNI)
:W.
F,B. Smithwick
UNICEF Repr~qentativea .i .
Karachi PfXISTAN
EWMW78 ANNEX A nage v i
M R O W H O E
REP'RESENTATIVES FHOM U N I T W NA'I'IUPJS BODIES UNITED NATIONS CHILDREN ' S RJNc
(cont'd)
---
iW. W s k ? Wong Dtp:uty UNICEE' Hepresenttatlve Karachi PAKISTAN
-
Trmfessor Ghulan, J i l a n i C h i e f , Dtl?artment of 'inplied Psychology U n i v e r s i t ! ~ of Panjab UNICEF Corlsultant L3hore PAKISTAN
UNITED NATIONS RELIEF W O R K S AGENCY FOR PALESTINE REFUGEES
ANU
D r . J.B. McPhail C h i e f , P r e v e n t i v e Medicine D i v i s i o n 1:niter' Nations R e l i e f and Worlts Agency f o r P l l e s t i n e Refugees Headquarters B e -. i r u t LEBANON
F O O D ANT, AGRICULTURE ORGANIZATION
D r . ?. Pro j a Konchi Chief, N u t r i t i o n S t r v i c e s S e c t i o n Nutrition Division Food an(' A g r i c u l t u r e O r g a n i z a t i o n Rome ITALY
OBSEFtVERS FROM IIFIERNATIONAL COUNCIL OF NURSES, Geneva
OTHER ORGANIZATIONS_ Mrs. I m t i s z Kamal P r e s i d e n t of Trained Nurses A s s o c i a t i o n College of N ~ ~ r s i n p , J ~ n n n hpost-Graduate Medical Centre Karachi PAKIGTAN
TRAINED NURSES ASSOCIATION PAKISTAN
Mrs. Harnida Osman public Relationo Officcr
Trainei! N ~ P 3 e sA s s o c i a t i o n of P a k i s t a n Karachi PAKIOTAN
-
WHO EMRO
EM/MCH/78 ANNEX A p n p vi i
OBSERVERS FROM OTIHER ORGANIZATIONS (~ont'd) INTERNATIONAL UNION FOR CfIILD WELFARE, Geneva Begum Gharnar Isnahani Child Welfarc Sooial Worger
Chairman for Homeless Babies Adviser on Child Welfare for All P d k i s t a l l Women Aoooci~tion, K2rhchi Chairman of Ghamar Ispahani Children's Club Karachi PAKISTAN WHU SECKhTARIAT
Dr. A.H.
Taba
Director
Recional Office for the Eiis L a z . l i Mediterranean
Dr. G . H . Jallad Dr. O . M . S . Mellander
Adviser on Matcrnal and Child Health Adviser on Nutrit,ion Consultant
Regional Office for the Easterri Medi tcr-ranean Regional Office for the hastern Mediterranean
Professor T.D. Stahlie
Head, Department of Paei'istrics and Vlce-Dean, Free University, Amsterdam, Holland Professor of Mental Health Faculty of Medicine, Khartoum University, Khartoum, Sudan Professor of Maternal and C h i : ? Health, School of Public Health, Chairman Department of Community Health Practice, American University of Beirut, Beirut, Lebanon Professor of Clinical Nutrition, American University of Beirut, Aeirut, Lebanon
Dr. T . A . Baasher
Temporary ACviser
Dr. J.K. Harfouche
Temporary At viser
D r . S.
MoLaren
T ~ n : > c m r y ArJviser
EM/MCH/~~
WHO EMRO
ANNEX A page v i i i
WHO SECRETARIAT (Cont ' 2 )
Dr. S.M.K.
Wasti
Tern mrarir 4dviser
Professor of Meclicine (~aedintrics), King Edwards Medical College, Lahore, West Fakistan Nutrition Institute, Islamabad, West Pakistan Regional Office for the Eastern Mediterranean Regional Office for the Eastern Mediterranezn
Dr. M . R . Barakat Miss C . Cartoudis Miss N. doheir
Iqutrition Atlviser Conference Officer Secretary, MCH
NATIONAL PREFARATOHY COMMITTEE Chairman Lt. Col. K.A. Rashid
Members
Dr. M . Jalaluddin Dr. M . Hassan Mr. A . S . Bazmi Ansari Mr. Sabihuddin Ahmad Dr. Sarwar H. Rahman Miss Wazir Begum Mr. S. Ehtram Ali a r c i r r ! Mr. M.A. T Mr. G.L. Badar
EM/McH/~~ ANNEX B paae i
LIST Or" -
WOPJtIs2ROUi'S
I"ESRS
WORKING GRO&
ON NUTRI_Ti! . .
Chairman Rapporteur Members
Dr..
(Xrs.) Lam'an Zaki
Ur, . 2.3 A l l Taha Miss Abebz Gobezie
(Ethiopia) (Iran) (Iran) (Iraq) (~orZan) (Kuwait) (Libya) (~akistan) (Pakistan) (pakistan) (Pakistan) (Pakistan) (Pakistan) (Pakistan) (Sudan)
Dr,
,i
Xahimz-:Zr;gzn
D r . Pi. Ahzri D r . H.S. Al-Sharbati D r . T. Karadsny
Dr, Dr.
.
Ihrahim Ahmad.
(Mrs.) S. Laageli
D r . (Mrs. ) S. Bano Agha Dr. Dr.
(Mrs. ) X.H.
A. Khan
M.H.. Rahman
Begum Shamar Ispahani
D r . Newab Khan
..
D r . S. Cha7~dari
Mrs. A. Gani D r , S.A.R. Dr. R l i Taha.
(Mrs. j N.H. Tssa
(Urn)
D r . A. Taa E l Din
(UAR) (Yemen) (FAG) (UNRWA)
D r . A.13. Al-Sharie D r . F. Proja Ronchi 3r. Mr.
B . McPhail F.F. Smithwick
(UNICEF) (UNICEF)
M r . Wah Wony; WHO S t a f f Dr.
D.S. McLaren Mellandcr Barakat
D r . O.M.S.
D r . M.R.
WHO EM30
WORKING G R O U P ON
MENTAL HEALTH (~ehnon) (Iraq)
Chairman Raonorteur Membirs --
Dr8. H.H.
J-lloul
D r . S. ~ 1 - ~ i k r i t i
D r . ?. Iiac'&u
(Ethiomia) 'Iran) (Iran) (Pakistan) (Pakistan) Rahi!ntoola (~akistan) (Somalia)
Dr.. M. Ghtzrib Dr. P . .
Emamj
D r . M.H.
Chowdhur:r
D r . H. A l i Khan
Dr.
(Mrs.) R.J.
Dr. M. A l i Nur D r . N. Ghabrs
(S.A.R.) (~hailanc') (u.A.R.)
Dr. . ' 1
Vichitbanc'hs
D r . M. Diwani D r . A . F. El-Sher.bini
(u.A.R.) (UNICEF)
Professor Ghulam J i l a n i
M r s . Imtiaz KamaL
trn) (TNA , "ahistan)
Mrs. Hamida Osman G O Staff D r . T.A. Baasher
WHO EMRO
EM/MCn/78
ANNEX C ?age i
AGENDA 1 . 2 . Opening of the Seminar Election of Officers 2.1 Chairman Two Vice- chairmen
2 . 2
2 . 3 Rapporteur
3 . 4 .
Adontion of Agenda Health of the Pro-School Child (1-5y e a m ) 4 . 1 4.2 ~ einitions f Vital and Health Statistics
4.3 Gmwth and Development 4.4 Nutrition 4 . 5 Social Environment 5 . Health Problems of the re-School Child 5.1 Hereditarv Diseases
5 . 2 Malnutrition
5 . 3 Communicable Diseases 5.4 Mental and Psyrhol ogi r a l Pmhlerns
6.
~eaithNeeds of the Pre-School Child 6. l Environrnent,al H e a l t h
6.2 Prevention of Disease
6 . 3 Nutrition
6 . 4 Mental Health 6.5 Mcdiosl Csrc
6 . 6 Rehabilitation
BM/MCH/~R
ANNEX
W I I O Ern
C
page ii
7.
Health Services to mdct thc.necdn.of the Pre-School C i l i l c l
7 . 1 7.3 7.'I 7.5 7 . 6 7 . 7 8.
Domiciliary Carc Services
7 . 2 Health Centre Services Hospital Services Child Guidance Services
Rehabilitation Services Sup.-ilementary Feeding Prugralumes
Recreational and Educational Services
rerstinnal Requil~e~~~anLa Lo Meet Vie Needs
of Xne yre-Ychool Chiid
8 . 1 Doctors 8 . 2 NUI-S~S
8.3 Health Visitors 0 . 4 Miclwlves
6 . 5 0.G
Auxiliary Health Workers Suclal Workers
9.
Summary of concLusions and general eiscussion Recornmendations
1 0 . Closing of the Seminar 1 0 . 1 DiSCUSSion and ApDroval or' the Provisional Report
1 0 . 2 Closin~ Session
WHO EMRO
'
EM/MCH/78 ANNEX D t
i
PROGRAMME OF THE Sh'MI.VAR 1.
MONDAY, 2 6 FEBRUARY 1 9 6 8 INTERCOWLNENTAL HOTEL -..* . . , . Registration oS f'artlc1.rlant.s OPENING .--..----SIBSION
--
E.r;iress : : y H.E. Kazi Anwrrrul Haque, Central Minister of E?ucation, Health Labour ant Social Welfare, Islamabar? AcXress bg Dr. A.H. Taba, Director, Worl? Health ~rganizition, Eastern Mediterranean R c g i o n
Aedress by Brig.-dierC.K. Hassan, Dirtctor-General of Health and Joint Secretary to Government of Pakistan (ex-officio), ~slamabad A ~ I ' L ~b :~ sMi-.
F,F. S m i t h w i c l r , UNICEF
Re:>resentative a. i. , Pakistan rnCESS Transfer of the grouisto the JINNAH POST GRADUATE lrnOIC.'IL CENTRC --..
-
FIRST . . -FLEI~ARTSESSION Election of Cfficers: Chairman, 2 ViceChairmen, Ha?pcrteur INTRODIJCTlON by Dr. G . Jallad, Regional Ar'visr,r nn M.?vlrit.pr3na1 and Child Health. WHO ;3TTRODUCTION by ?rofessor T.D. Stahlie ; WHO Consultant: "HEALTH PROBLEMS AN11 NEEDS OF TIiE CHILD (1-5 years) IN THE EASTFXN MEDITERRANEAN REGION"
4 . 0 0 ?.m. 2.
-
6.00 a.m.
Visit to Government Institutions ~~ ~
TUESDAY, 27 F E B R U A R Y ~ ~ ~
. .. . . . ..
..
8.00 a.m.
0.30 a.m.
Steerin,& Com~nittec . .
EM/McH/~~ ANNEX D ?age ii i
WHO EMRO
i !
TUESDAY, 27 FEBRUARY 1968 { ~ o n 'd) t
8.30 a.m.
-
10.30 a.m.
--SECOND TLENAW SESSION Tresentation a n ( ! Discussion on Agenda. iterns 4 : . n S 5: "HEALTH AND HEALTH PROBLEMS OF THE IFE-SCHOOL CHILD (1-5years)". Discussion lea?er Profgssor S.M.K.Wasti, Irofessor of Melicine (Pae6iatrics), Xing Edward Medical Collegc, Lahore, West Pakistan
I
: I I
!
i I i
RECESS STATEMENTS BY PARTICIPAWS ON ITEMS
4
an?
5
GENERAL DISCUSSION WORKING GHOUPS WORKING GROUP No. 1 Prtscntation anc' Discussion on Agenda items 5.2, 6.3 and 7.6: "NUTIIITIONALI'ROBLEMS AND NEEDS OF THE ;'RE-SCHOOL CHILD (1-5 years) " Discussibn l f n c ! e r Proressor D.S. McLaren, Prufisaor of Clinic~l Nutrition, and Director, Coivmbil.,. A.U.B. Nutrition Research progrwnmc, American University
.
or B t i ~ . u i , , B e i ~ . . i L ,Labitnun
WORKING GROU? No. 2 Presentation z i n c Discussion an A~entld items 5.4 a n ( ! 6.4: "MEIWAL HEALTH OF THE PBE-SCHOOL CHILD, 'PROBIJ3MS A N D NEEDS". Discussion lereer ;r.ofsssor T.A. Baasher, of Mental Health, Faculty of McOicine, Khartoum University, Khartoum, S u i ian 3.
WEDNESDAY, 28 I"IIDIuAnY 1 9 6 8
8.00 3.m. - 8.3 3.m.
Steering Comn~ittee
WHO EMRO
EM/McH/~~ ANNEX D page iii
!
WEDNESDAY, 26 FEBRUARY 1 . ~ 6 8 (~ont 'd) 8.30 a.m. - 10.30 a.m.
THIRL! PLENARY SESSION Presentation and Discussion on Agencla Items 6 arai 7: "NEEDS OF THE ?RE-SCHOOL CHILD (1 -5 scars) AND hEETIIVG THESE NEEDS". Discussion lender Dr. J.K. Harfouche, Trofessor of Maternal and Child Health, School of Pilblic Health, American University of Beirut, Beimt, Lebanon RECESS REPORTS OF THE WORKING GROUPS Nos. 1 and 2 ((NUTRITION AND MEWTAL HEALTH) STATEMENTS BY PARTICITAhTS ON ITEM2 6 and 7 THIHD PLENARY 3E33ION (~ont'r')
1: I.
I: [
k I:
I1
STATEMENTS BY PARTICIPANTS ON ITEMS 6 a n c l 7 (contie) GENERAL DISCUSSION 4. THURSDAY, 29 FEaRUPRY 1968
8 . 0 0 a..m.
-
8 . 7 1 0
a.m. a.m.
Stcerint Committee Presentaticn and Discussion on Agenr'a item <: "lnERSONNEL REQUIREMENTS TO MEET THE NEDS OF THE ?RE-SCHOOL CHILD". Dicrcuonion 1cat"cr Prof.A.F. i 3 1 Shorhlni, professor of M,%ternal :,nC Child Health, High Institute of Public Health, Alcxanrlrin, Unite6 A s c b Rcnubllc
8.X)
n.m.
- 10.30
RECESS STATEMENTS BY PARTICIPANT3 GENERAL DISCUSSION Afternoon
EM/MCH/78 ANNEX D page iv
WHO EMRO
5.
FRIDAY, 1 MARCH 1368 SATURDAY, 2 MARCH 1968
6 .
8 . 0 0 a.m.
-
Stzcrin~ Committ,ee
8.3 s.m.
FIFTH .
PLEKARY SESSION -. item
--
Discussion on Agenr!a
3:
"SUMMARY OF CONCLUSIONS AND IIECOMVENDATIONS". Discussion l e a d e r Prof'c:;sor \ i ' . U . S t a h l i e , WHO Consultant Agenda i t e m 10.1: ,
.
"DISCUSSION AND APPROVAL OF TEIE FROVISIONAL REPORT" RECESS
Eigenclo item 10.2: "CLOSIEIC SESSION".
WHO EMRO
EM/MCH/78 ANNEX E pagc i
LIST OF BASIC DOCUMENTS
........................................ EM/SEM.HLTH.CHILD/~ . Programe..................................... EM/SEM.HLTH.CHILD/~R~~.~ List of Participants and Observers............ EM/SEM.HLTH.CHI~/~ Rm.1 . . . Agenda . ,
. . .
Rev. 1
HEALTH PROBLEMS AND IEALTII NEED2 OF THE CHILD 1-5 YEARS, IN TIIE EASTERN &ITERR~NEAN REGION by Professo'rT.D. Stahlie, Head, Department of Paediatrics and Vice-Dean, . . . . . . . Free Universitjr; Amsterdnm, ~ollancl- WHO consultant. : .EM/SEM. HLTH.
-
........................ .......
CHILD/^
........................... EFFECT OF 'I'm SOCIAL ENVIRONMEFL ON THE HEALTH OF THE PRE-SCHOOL CHILD, 1-5 YEARS -
HEALTH AND HEALTH PROBLEMS OF THE PHE-SCHOOL, CHILD, by Dr. S . M . K . Wasti, Professor of Medicine (paediatrics) King R d w a r d Mndi cal College, Lahore, west . . . . . . . Pakistan - WHO Temporary Adviser EM/SEM.HLTH.CHILD/5
by Dr. J.K. Harfouche, Professor of Maternal and Child Health, Chairman.~e<irtment of Fublic Health Practice, School of Public Health, American University of Beirut, Beirut, Lebanon - WHO Temporary Adviser. EM/SEM.HLTH.CHILD/6
....
NUTRITION OF THE PRGSCHOOL CHILD - PROBLElvlS AND IEBDS - by Dr.D.S. McLaren,Professor of Clinical Nutrition, and Director, Columbia - AUB Nutrition Research Programme, Amcrican University uf Beirut, Bail-ut, . . . Lebanon - WHO Temporary Adviser EM/SEM.HLTH.CHILD/7
............. -
,
COMWNICABLE: DISEASES .IN PRE-SCHOOL CHILDREN AND THEIR PICDENTION by Dr. M. M . Hassan, Senior Paediatrician, Khartom Hospital, Ministry of Health, Khartoum, Sudan.. ....... EM/SEM.H~TH.CHIID/,/R
-
MENTAL HEALTH OF THE PRE-SCHOOL CHILD PROBLEW AND NEEDS - by Dr. T . A . Baasher, Professor of Mental Health, Faculty or' Medicine, Khartoum University, Khartoum, Sudan WHO Temporary Adviser.
-
..............EM/sEM.HLTH.C!HILD/~
HEALTH NEEDS OF THE PRE-SCHOOL CHILD (1-5 YEARS) AND MEETING THESE NEEDS by Dr. J.K. Harfouohe
.......................
-
EM/SEM.l~II.CI~~/lO
EM/MCH/7S ANNEX E page ii 11. 'JSUTCATTONAL APPROACH
WHO EMRO
$6 MGhT THE HIW2k-I NEEDS OF THE PRE-SCHOOL CHILE hy Dr. S . ' Al-~ikriti', Professor of Pr.e.ventiv.e and Social.Medicine. - .
-
and Assistant Dean, College of Medicine,
University of J&ghda'd, Baghdad, Iraq.. 12
..........E~SEM.HLTH. CH1b/11
PERSONNEL REQUIREMENTS TO MEET THE NWDS OF THE PRE-SCHOOL CHILD by Dr. A.F.El Sherbini, Professor of Maternal and Child Health, High Institute of Public Health, Alexandria, United Arab Re2ublic EM/SEM.HLTH.CHILE/12
-
............................
3
PERSONNEL REQUIREMEWS ANDTRAINING TO MEET THE NEEDS OF T m PRE-SCHOOL CHILD, 1-5 YEARS, IN PAKISTAN - by Dr. (Mrs.) A . K . Awan, Professor . . of Maternal and Child Health, ~nstitute'of mgierie alill Preveritlve Medlclne, Lahore, EwSEM.HLTH.CHILE/l> West , , , ,
................................... ...... LIST (IF RACKGROLIND MATERIAL
1 .
PROTECTING THE PRE-SCHOOL CHILD - Reoort on an International Symposium (Lake Como, 5 8 Auxust 196>), under the auspices of the Sixth International Con~ressof Nutrition Edited by Paul GyCcrgy and Anne Burgess, Lon6Ton.
-
2.
THE CARE OF WELL CHILDREN IN DAY-CARE CENTRES AND INSTITUTIONS - Report of a Joint W H O Expert Committee (with the participation of FAO, IL0,and UNICEF) - WHO Technical Report Series, No. 256, l % j . THE M ! I ? N A l 'L L Y SUBNORMAL
3.
CHILD WHO Technical Report Series, No. 75, 1S54. Report of a Joint Expert Co'mittee convened by WHO (with the participaL O and UNESCO). tion of United Nations, ?
-
4.
5.
JOIW FAO/WHO EXPERT COMMTTTkE ON m I T I O N WHO Technical Report Series, No. 245, 1962. ...... Information Bulletin No. 1 on administrative arrangements and Corrigendum 1
-