Rashtriya Bal Swasthya Karyakram Research Articles

Authors' reply.

Sir, We thank the authors for their interest in our article[1] and for highlighting the issue of anticoagulation for atrial fibrillation (AF) in children with valvular heart disease (VHD). There is little doubt that AF independently increases the risk of stroke across all age groups, however, the AF-related stroke incidence varies.[2] The presence of concomitant VHD, regardless of the disease type and severity, further amplifies the risk of stroke and thromboembolic events in AF.[23] There are no published studies in pediatric patients, specifically addressing the risk of AF in VHD or the issue of anticoagulation in atrial arrhythmias. An important explanation for the lack of data is that AF is quite rare in the pediatric population, unlike in adults. Therefore, management experience from the adult literature is used as a surrogate and is extrapolated to the pediatric age group. There has been considerable heterogeneity in the definition of valvular and nonvalvular AF, and the definitions have changed with successive editions of major guidelines. A consensus[4] published in 2014 defined nonvalvular AF as AF in the absence of prosthetic mechanical heart valves or hemodynamically significant valve disease, while the term “nonvalvular AF” was no longer used in the recent update.[5] AF evidently leads to an increased risk for thromboembolism in patients with mitral stenosis, but there are limited data for other valvular diseases. There are currently no specific recommendations for thromboembolic prophylaxis in patients with AF and mitral or aortic regurgitation. Recent guidelines reiterate the assessment of stroke risk using the CHA2 DS2-VASc score for patients with nonvalvular AF.[5] Although the data on the use of CHA2 DS2-VASc score for anticoagulation in AF in children are sparse, the risk of stroke with AF in children is very low as per the scoring system. It needs to be highlighted that the CHADS2 risk score was developed for patients with nonvalvular AF, and hence, some studies suggested excluding patients with valve disease, particularly rheumatic mitral valve disease, for risk assessment using the CHADS2 score.[26] Darby et al.[3] recommended the use of systemic anticoagulation in all patients with rheumatic valvular disease with AF, unless there is a contraindication. Nonetheless, the recent guidelines recommend the use of CHA2 DS2-VASc score for deciding anticoagulation therapy in patients with AF and mitral or aortic regurgitation based on post hoc subgroup analyses of large randomized controlled trials.[7] The 2017 European guidelines for the management of VHDs are silent about the use of scoring system when deciding anticoagulation in this population, highlighting the heterogeneity in the recommendations on the issue. The authors mention that novel oral anticoagulants (NOACs) should be considered as an alternative to Vitamin K antagonists (VKAs) in patients with aortic stenosis, aortic regurgitation, and mitral regurgitation presenting with AF (Class IIa, level of evidence B).[8] However, there is a lack of data on the safety and efficacy of NOACs in children. As explained above, the statement in the current guidelines[1] is based on the conflicting evidence available from the studies in the adult population. The use of VKAs is reasonable in children with AF and mitral or aortic regurgitation. However, we agree that the “decision to anticoagulate” should be individualized in children and prospective randomized controlled trials are needed to formulate risk stratification system to guide the use of anticoagulation in this pediatric subset. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgments The authors express thanks to Children's HeartLink Group (Ms. Bistra Zheleva, Ms. Adriana Dobrzycka, and Ms. Veera Rajasekhar), Pediatric Cardiac Society of India, and Dr. Arun Singh, National Advisor, Rashtriya Bal Swasthya Karyakram, Ministry of Health and Family Welfare, Government of India.

Author's reply.

Sir, We thank the authors for their letter and appreciate their effort in bringing the issue to our notice. We agree with the authors and hereby clarify that the gradient of 20 mmHg mentioned in points “i” to “v” under the subheading “Indications for intervention” in coarctation of the aorta in the guideline document[1] refers to the gradient between upper and lower limb systolic blood pressure, instead of Doppler gradient, as per the European Society of Cardiology guidelines.[2] Point “v” should be read as follows: v. Intervention is not indicated if gradient between upper and lower limb systolic blood pressure is <20 mmHg with normal left ventricular function and no upper limb hypertension (Class III). We agree that Doppler peak gradients tend to be overestimates, as they reflect the peak instantaneous pressure gradient instead of the peak-to-peak pressure gradient, and hence are not recommended to decide intervention in coarctation of the aorta. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgments We express thanks to Children's HeartLink Group (Ms. Bistra Zheleva, Ms. Adriana Dobrzycka, and Ms. Veera Rajasekhar), Pediatric Cardiac Society of India and Dr. Arun Singh, National Advisor, Rashtriya Bal Swasthya Karyakram, Ministry of Health and Family Welfare, Government of India.

Retinopathy of prematurity: Overview and highlights of an initiative to integrate prevention, screening, and management into the public health system in India.

Purpose:In India, more than 800 special newborn care units (SNCUs) have been established since 2008 in government facilities. More preterm infants are now surviving and blindness from retinopathy of prematurity (ROP) is increasing. The aim of the Queen Elizabeth Diamond Jubilee Trust's initiative (2012–1019) was to improve the quality of neonatal care and integrate ROP services into the government health system using expertise in the government and nongovernment sector in four states in a sustainable and scalable manner.Methods:State Ministries of Health were engaged and collaboration was established between three government programs (Ministry of Health and Family Welfare, Rashtriya Bal Swasthya Karyakram, and blindness prevention) and relevant professionals. Extensive training took place and equipment was provided. Implementation was guided by a multidisciplinary National Task Force and was monitored by state coordination committees. The Task Force appointed technical expert groups to support implementation through advocacy, information, education and communication materials, operational guidelines, a competency-based training curriculum, and an online database and website.Results:Twenty-two ophthalmologists in government facilities were trained to screen for ROP and nine to treat ROP. Almost 13,500 preterm infants were screened in 17 SNCUs and 86% of the 456 infants with sight-threatening ROP were treated. An educational resource using latest pedagogy based on key domain areas for best practices for small and preterm neonates including ROP has been developed and pilot tested and is being evaluated and scaled up.Conclusion:All four states are scaling up services or have plans to scale up, and several other states have started the initiatives.

Magnitude and pattern of birth defect babies at Bhopal district early intervention center under RBSK’s 4Ds approach: an observational study

Background: As per World Health Organization (WHO) congenital anomalies are also known as birth defects, congenital disorders or congenital malformations. Most common and severe congenital anomalies are congenital heart diseases, neural tube defect and Down’s syndrome. No data on the magnitude of congenital anomalies is available in India. Thus, the study aims to determine the magnitude and pattern of babies with birth defect reporting at District Early Intervention Center, Bhopal in children aged 0 to 6 years.Methods: This was an observational study conducted at DEIC, Bhopal under Rashtriya Bal Swasthya Karyakram services, over a period of one year. Children between 0 to 6 years visiting the center and belonging to Bhopal district were included in the study. Data entry was by Microsoft Excel and analysis was by Epi info.Results: 2891 children were registered for the study out of affected children 18.7% of them were diagnosed with Developmental delays while birth defect was observed in 4.3% cases. Of the birth defect cases majority i.e. 37.7% had congenital heart disease and 16.7% had congenital hearing loss. No case of retinopathy of prematurity was registered.Conclusions: The study also helps to know the magnitude and pattern of congenital anomalies. Any effective health intervention will reduce both direct costs and out-of-pocket expenditure.

Training of children’s surgical teams at district level in low- and middle-income countries (LMIC): from concept to reality—a south to south initiative

Training of children’s surgical teams at district level in low- and middle-income countries (LMIC): from concept to reality—a south to south initiative

Prevalence of specific learning disabilities among Gujarati medium primary school children

Introduction: Learning disability in children is an assorted group of disorders where the individual unpredictably fails to proficiently attain, regain, and use information. Objective: The objective of this study was to measure the prevalence of specific learning disabilities (SpLDs) such as dyslexia and dysgraphia among the Gujarati medium primary schoolchildren. Methods: A cross-sectional study was conducted in public schools of Gujarati medium among children aged 7–12 years from the second, third, and fourth standard. After obtaining a sociodemographic profile, a multilevel screening approach that begins with the identification of educational backwardness followed by exclusion of vision, hearing impairment, chronic health conditions, and subnormal intelligence was carried out among these children. In the last stage, remaining children were subjected to the National Institute of Mental Health and Neurosciences test for SpLDs. Results: The prevalence of SpLDs was 9.6% in sampled children, whereas 7.4%, 8.6%, and 7.1% had dyslexia, dysgraphia, and dyscalculia, respectively. Among children diagnosed with SpLD, 65.7% (n=25/38) of children had a combination of all three types of SpLDs. Conclusions: This study suggests that the prevalence of SpLDs in public schools is the same as private schools and metro center. We have used a multilevel screening approach that can be utilized for early identification of children with SpLD by Rashtriya Bal Swasthya Karyakram team without imposing load on specialist services. There is a need for sensitization of school teacher for timely referral, remediation strategies, and policy interventions to improve school performance and to reduce dropouts of schoolchildren.

National Program for RMNCH + A: Newer Strategies for Improving the Newborn Health in India.

RMNCH+A is a platform for delivering adolescent, maternal, newborn and child health in an integrated manner using a life cycle approach. The new initiatives under this strategy that would impact newborn health include antenatal corticosteroids in preterm labor, delayed clamping of cord at birth, skin-to-skin contact at birth and Kangaroo mother care, Family participatory care, Lactation management centers and care beyond newborn survival under the Rashtriya Bal Swasthya Karyakram. Even though the coverage of many of the existing initiatives has been moderately high, there are concerns about the quality of delivery of these interventions and slow progress in the roll out of the newer interventions. Quality assurance initiative such as Dakshata and LaQshaya will also contribute to improved newborn health as we proceed towards the Sustainable development goals (SDG) 2030 targets for newborn and child survival.

Health Conditions screened by the 4D`s Approach in a District Early Intervention Centre (DEIC) under Rashtriya Bal Swasthya Karyakram (RBSK) Program

Health Conditions screened by the 4D`s Approach in a District Early Intervention Centre (DEIC) under Rashtriya Bal Swasthya Karyakram (RBSK) Program

Challenges and Solutions in Implementing Hearing Screening Program in India.

Hearing is the key to learning spoken language, performing academically, and engaging socially for children. Degree of hearing loss quantifies the hearing ability from mild to profound, based on the audiometric findings for an individual across certain frequencies or pitches. Early identification and appropriate intervention is the prime need. A probable strategy is to ensure that every newborn is screened for possible hearing loss at the birth in the hospital. In India, hearing screening facility is mostly available to newborns brought into tertiary hospitals. Some of the key issues in the implementation of the program identified are lack of human resources, inadequate infrastructure, equipment-related shortcomings, and low priority for hearing impairment (HI) prevention. The Government of India initiated efforts toward prevention and control of HI, i.e., National Program for Prevention and Control of deafness and Rashtriya Bal Swasthya Karyakram which are significant milestones in the implementation of systematic nationwide hearing screening programs.

Assessment of risk factors for developmental delays among children in a rural community of North India: A cross-sectional study.

BACKGROUND:Initial formative years in every children's life are critical for their optimal development, as these frame the foundation of future well-being. With a varied prevalence of developmental delays (DDs) in the world and most of the studies representing the hospital-based data. The present study was aimed to find the prevalence and risk factors for DDs (domain wise) in children aged 2 months to 6 years in the rural area of North India.METHODS:This was a cross-sectional study in which a multistage random sampling technique was used. From 30 Anganwadi centers, 450 children aged 2 months–6 years were taken in the study. Rashtriya Bal Swasthya Karyakram screening tool developed by the Ministry of Health and Family Welfare, India, was used for developmental screening. Binary logistic regression analysis was done to identify the predictors for DDs (domain wise).RESULTS:Seventy-three (16.2%) children were found to have DDs and 60 (13.3%) children had the global DDs. About 84/421 (20.0%) children had cognitive delay, followed by 43/450 (9.6%) children who had delay in speech and language area. About 17/190 (8.9%) children had social delay while 26/407 (6.4%) children had hearing and vision impairment. Gross motor delay was seen in 24/450 (5.3%) children and 16/300 (5.3%) children had fine motor delay. Gestational age (adjusted odds ratio [AOR] – 13.30), complications during delivery (AOR – 25.79), meconium aspiration (AOR – 12.81), and child never breastfed (AOR – 8.34) were strong predictors for the delay in different domains of developmental milestones.CONCLUSION:Socio-economic, ante-natal, natal and post-natal factors should be considered for prompt identification and initiation of intervention for DDs.RECOMMENDATION:There is a need for increasing awareness and knowledge of parents regarding the achievement of developmental milestones according to the age. A multipronged approach to the holistic treatment of developmentally delayed children for early intervention is required.

Congenital heart disease: factor affecting it and role of RBSK in dealing with situation

Background: Congenital heart diseases (CHD) is the second leading cause of death in infancy and childhood. So the purpose of this study to know socio-demographic profile and the maternal risk factors affecting CHD, and the role of RBSK in screening with respect to CHD.Methods: A cross-sectional study was conducted during June to October 2016 in Ahmedabad city. Parents of 169 children with CHD who were beneficiaries of RBSK during the previous 3 months were interviewed.Results: The majority of children were in the age group of 0-3 years 49.7% (mean±SD= 4.26±4). Majority of families belonged to the lower middle class IV (41.4%). 44% of mothers had primary education. Mothers with age &gt;30 yrs were 55.6%. Only 30.9% of mothers had taken folic acid during the periconceptional period. Mothers with previous adverse pregnancy outcome were 40.2%. Maternal stress and high blood pressure were present in 33.7% and 24.8% of the mothers respectively. 48% of children were diagnosed through Rashtriya Bal Swasthya Karyakram (RBSK).Conclusions: Lower middle class, lower maternal education, advanced maternal age, low folic acid intake, previous adverse pregnancy outcome, maternal stress and high blood pressure were the leading risk factors for CHD. RBSK is playing important role in screening and diagnosing of patients.

Rashtriya Bal Swasthya Karyakram: Bringing thyroid to center-stage

Rashtriya Bal Swasthya Karyakram: Bringing thyroid to center-stage

A cross-sectional study to evaluate the functioning and infrastructure of DEIC, and client satisfaction Ujjain and Indore districts established under RBSK.

Background: Rashtriya Bal Swasthya Karyakram (RBSK) is newly launched programme under NRHM, under which screening of 0 to 18 yr children is done and The DEIC promptly responds and manages all issues related 4Ds. Objective: To evaluate the functioning and infrastructure of DEIC, and client satisfaction. Materials and Methods: Observational Check List according to norms used for assessment of facilities, staffing pattern, and Semi structured questionnaire used for client satisfaction.. Result: DEIC of Indore and Ujjain district were deficient in staff and infrastructure. Among all referred cases to various facility 10.24% were referred to DEIC Indore while in Ujjain 20.1% were referred to DEIC among all the referred cases only 5.2% and 6.01% reached the DEIC Indore and Ujjain respectively, among which birth defect were found 0.7% and 0.8% , deficiency disease cases were 0% and 0.2% respectively in Indore and Ujjain district, childhood disease were 1.49% and 3.48% respectively in Indore and Ujjain district and developmental delays and disease were 3.46% and 1.62% respectively in Indore and Ujjain district. 76.92% beneficiaries were dissatisfied with the referral service and DEIC Staff (Behavior and Availability) in Indore while in Ujjain 65.3% were dissatisfied. Beneficiaries remained dissatisfied with regard to expenses, 71.1% in Indore and 63.4% in Ujjain. Conclusion: There was a deficiency of staff and infrastructure in DEICs of both Indore and Ujjain, There was lack of proper referral system between MHTs and DEICs in both the districts thus affecting the rendition of services to beneficiaries under RBSK program. The beneficiaries were dissatisfied with the Referral services and Availability and Behavior of DEIC Staff.

Study of knowledge, attitude and practice of AYUSH doctors, evaluation of MHTs working in RBSK and client satisfaction

Background: Rashtriya Bal Swasthya Karyakram (RBSK) is newly launched programme under NRHM, under which screening of 6 month to 18 year children done by AYUSH doctors. The objective was to evaluate the infrastructure and staff available with mobile health teams (MHTs), knowledge, attitude and practice (KAP) of AYUSH doctors regarding 4Ds and client satisfaction for screening done by AYUSH doctors. Methods: Two blocks from each Indore and Ujjain district were randomly selected and observational check list made according to norms of RBSK was used for assessment of staffing pattern, availability of equipment’s with mobile health team. A pretested questionnaire is used to evaluate KAP of AYUSH doctors and client satisfaction. Results: According to the norms of Rashtriya Bal Swasthya Karyakram all the mobile health teams were deficient in terms of human resources and equipments. All the doctors under study were graduate in AYURVEDA, most of them were trained for RBSK and having good knowledge regarding the 4Ds, a significant difference was observed in their attitude and practice with regards to referrals and examination of children. Most of the beneficiaries were satisfied with the screening services. Conclusions: All Mobile Health Teams were deficient in paramedical staff and tool kit for screening where the used tools were replaced only once a year. And there is difference in attitude and practice of MHT doctors.

Comment on "South Vietnamese Rural Mothers' Knowledge, Attitude, and Practice in Child Health Care".

The paper by Thac et al. is an important paper from the point of view of health care providers and policy makers in the context of Integrated Management of Childhood Illnesses (IMCI) in developing countries like India [1]. IMCI is an integrated approach which includes three main components [2]: Improving case management skills of health-care staff. Improving overall health systems. Improving family and community health practices. The paper highlights the importance of the third and valuable component of IMCI, that is, “improving family and community health practices” by health education of mothers of under-five children. The figures mentioned in the paper clearly show that it is successful in achieving this third component. India has made notable strides in tackling neonatal and childhood illnesses through a number of initiatives. These are in the form of addition of neonatal component in IMCI (IMNCI), training of community level grass-root workers such as Accredited Social Health Activists (ASHA) and Anganwadi Workers (AWW), Home Based Neonatal Care (HBNC), facility based IMNCI, infant and young child feeding practices (IYCF), and Rashtriya Bal Swasthya Karyakram (RBSK) to name a few [3]. Health education and training of grass-root workers are being done in India, but organized component of health education of mothers needs to be incorporated for improving health practices at family and community level. This can be systematically introduced at national level using the community based platforms of Village Health Sanitation and Nutrition Committees (VHSNC) and Mahila Arogya Samitis (MAS) in India.

Surveillance of Anaemia: Mapping and Grading the High Risk Territories and Populations.

Surveillance of anaemia is an ongoing process for assessing iron status and anaemia prevalence among individuals and the communities they live in. Measuring blood haemoglobin levels is the commonest method espoused worldwide for screening individuals and populations for anaemia and iron deficiency. World Health Organization (WHO) proposed a classification of public health significance of anaemia in populations on the basis of prevalence estimated from blood levels of haemoglobin. India falls under "Severe public health problem" category. An attempt has been made to categorise "Severe public health problem" into grades of severity that will help in prioritising the states and districts for targeted action. To adapt the "WHO Classification of anaemia as a problem of public health significance" and to use the same to identify and map high risk population groups in the southern states of India. The category of 'Severe Public Health Problem' has been graded based on prevalence of anaemia. Secondary data published in the District Level Household and Facility Survey - 4 is analysed for five states and 1 UT (Union Territory) of southern part of India. Choropleth Mapping was done to visually depict the intensity of anaemia problem across the geographic territories. Children from 6 months to 59 months were having highest prevalence of both, anaemia (68%) and severe anaemia (10%). This was followed by pregnant women aged 15 to 49 years and Girl Child 6 to 9 years. Four of the Southern states of India including Andhra Pradesh, Karnataka, Telangana and Tamil Nadu fall in the Grade 2 SPHP (Severe Public Health Problem). The sixteen districts fall under Grade 3 Severe Public Health Problem in the states of Andhra Pradesh, Karnataka and Telangana, require special focus for identifying and addressing the determinants of such high prevalence of Anaemia. These populations and territories require priority in the Government of India's Rashtriya Bal Swasthya Karyakram (RBSK) in the National Health Mission to address iron deficiency anaemia. The problem needs to be addressed through dietary diversification and improved access to foods that have high levels of bioavailable iron, including animal products apart from iron supplementation.

Review of Rashtriya Bala Swastha Karyakrama and Utilization of Referral Services in Urban Field Practice area of Bangalore Medical College

BACKGROUNDThe Rashtriya Bal Swasthya Karyakram RBSK aims early detection and management of the 4Ds - Defects at birth Diseases in children Deficiency conditions and Developmental Delays including Disabilities in children in the community which are hidden and to provide service for them at District early intervention centre DEIC.OBJECTIVETo assess the magnitude amp distribution of the health conditions identified under RBSK by 4Drsquos approach and the utilization of referral services pertaining to RBSK in urban field practice area of Bangalore medical college and research institute.METHODOLOGY All Government and Aided schools ampAnganawadis present in urban field practice area of Bangalore Medical College amp Research Institute.After obtaining permission from respective authorities data pertaining to RBSK health checkup was collected from schools and Anganawadis health checkup registers and child health cards. Information regarding Utilization of Referral services was obtained by interacting with children during school hours and further information was obtained from parents by interaction using semi-structured pre tested and pre validated closed ended questionnaires with the help of community health workers of the areaRESULTS Total 1232 children were screened. Out of which 5 children were found to have birth defects 16 children were found to have some kind of deficiency 100 children were found to have diseases and 31 children were found with developmental delay including disabilities. Here in our study 12.3 children deprived of good health due to 4Ds. Among 152 children referred only 78 children utilised the referral services.CONCLUSION We observed that still there are many children are undiagnosed and deprived of treatment for curable diseases. Child Health Screening and promotion of Early Intervention Services is most beneficial for improvement in health status of children and RBSK should be extended to private schools to reach more children.nbsp

Moving from Survival to Healthy Survival through Child Health Screening and Early Intervention Services Under Rashtriya Bal Swasthya Karyakram (RBSK).

For negating the impact of early adversities on the development and ensuring a healthy, dynamic future for all children, Ministry of Health and Family Welfare in 2013 launched a programme for child health screening and early intervention services as Rashtriya Bal Swasthya Karyakram (RBSK) which aims to improve the quality of life with special focus on improving cognition and survival outcomes for "at risk" children. It has a systemic approach of prevention, early identification and management of 30 health conditions distributed under 4Ds: Defects at birth, Diseases, Deficiencies and Developmental delays including Disabilities spread over birth to 18y of age in a holistic manner. There is a dedicated 4 member Mobile Health team for community screening and a dedicated 14 member team at District Early Intervention Center (DEIC) for comprehensive management. Existing health infrastructure and personnel are also integrated and utilized in this endeavor. Defects at birth are screened at Delivery points, home visits by accredited social health activist (ASHA), Anganwadi centers and at schools. Developmental delays are evaluated at DEIC through a multidisciplinary team with interdisciplinary approach. Five thousand four hundred eighteen dedicated Mobile Health teams have screened a total of 12.19 crore children till Dec.14. From April to Dec. 2014, 4.20 crore children were screened, of which birth to 6-y-old children were 2.13 crore while 2.07 crore were from 6 to 18 y. 17.7 lakh children were referred to tertiary centers and 6.2 lakh availed tertiary care. 50.7 lakhs were found positive for 4Ds; 1.35 lakhs were birth defects. RBSK is a step towards universal health care for free assured services.

Estimation of magnitude of various health conditions under 4Ds approach, under RBSK Programme in Devendranagar block of Panna District, Madhyapradesh, India

Background: The Rashtriya Bal Swasthya Karyakram (RBSK) aims early detection and management of the 4Ds - Defects at birth, Diseases in children, Deficiency conditions and Developmental Delays including Disabilities in children in the community which are hidden may be due to unawareness or unaffordbility for treatment. Methods: We followed the operational guidelines of ‘Child Health Screening and Early Intervention Services’ under RBSK. Surveys done along with RBSK team for 6 months. Results: Total 26977 children were screened. Out of which 53 children were found to have birth defects, 434 children were found to have some kind of deficiency, 21768 children were found to have diseases and 113 children were found with developmental delay including disabilities. Globally, 200 million children do not reach their developmental potential in the first five years because of poverty, poor health, nutrition and lack of early stimulation. Here in our study 83% children deprived of good health due to 4Ds. Conclusion: We observed that still there are many children are undiagnosed and deprived of treatment for curable diseases. Child Health Screening and promotion of Early Intervention Services is most beneficial for improvement in health status of children in rural community.

Newborn hearing screening: present scenario.

In 2009 many countries of the world met to discuss newborn and infant hearing screening current issues and guiding principles for action under World Health Organization (WHO) banner, though most of the countries who had begun this work as universal program or high risk screen do not have exact data and protocol. The developing countries also decided to become part of it and common guideline was proposed. India being part of it included hearing screening as one of the 30 diseases to be screened under Rashtriya Bal Swasthya Karyakram (RBSK). This article discusses all these issues of newborn hearing screening in the world and India.