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Dr. Prakash D.VaishnavAssociate Professor,
State Institute of Health & Family Welfare (SIHFW),
Gandhinagar, Gujarat
State Initiatives in Maternal and Child
Nutrition
1
Dr.Gautam Nayak
State Nodal Officer State Nutrition Cell,Gandhinagar
Gujarat
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Sl. no Indicator Current Status Target 2015
1 Maternal Mortality Ratio 148 (SRS) 2009 100
2 Infant Mortality Rate 48 (SRS) 2009 30
3 Total Fertility Rate 2.5 (SRS) 2008 2.1
MDG Goal1990-2015Swarnim Gujarat Goal2011-2015
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TREND OF CHILD MORTALITY RATES
0
20
40
60
80
100
120
NFHS I '92 NFHS II '98 NFHS III '05
Neonatal Infant Underfive
4033
6963
85
61
50
106
42 .
/
3
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RISKS of being malnourished...
Reduced physical activity
Lowered resistance to disease
Increased risk of mortality
Learning difficulties
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What are the causes of childhood death?
Under-nutrition contributes to 53% of all child deaths Source:
WHR 2005
Diarrhoea, 15%
Measles, 8%
Pneumonia, 19%
Perinatal, 20%
Others, 28%
HIV/AIDS, 3%
Malaria, 7%
Malnutrition53%
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Critical Points for Nutrition in the Life-Cycle
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Growth &
development
HouseholdFood
Security
Adequatecare
of children and women
HealthHealth
Services
EDUCATION
Adequate Psychosocial
dietary well being Health
intake
Potential resources
Immediatedeterminants
Manifestations
Source: UNICEF
Underlyingdeterminants
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Health
Rural/Tribal/Urbandevelopment
NIROGI BAL VARSH-2008
Pregnancy
School
Adolescent
New born
InfantPreschool
8
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Nutrition Intervention Strategy
9
Evidence to action
Life cycle approach
Holistic intervention
Integrated efforts
•Adolescent•Reproductive age•Pregnancy•Lactating•Infants•Under five•School
•Health•WCD•Education•Agriculture•Civil supply
•International &National surveysState surveys ,
•Monitoring & evaluation data
• Macro nutrient• Micronutrients• Food gap• Food hygiene
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Jammu & Kashmir
Uttaranchal
Uttar Pradesh
Bihar
Arunachal Pradesh
Manipur
MizoramTripuraWest
Bengal
Orissa
Andhra Pradesh
Tamil Nadu
Kerala
Karnataka
Goa
Maharashtra
Madhya PradeshGujarat
Rajasthan
HaryanaDelhi
Punjab
Sikkim
Assam
Meghalaya
Andaman & Nicobar Islands
Lakshadweep
Pondicherry
Karaikal (Pondicherry)
Dadar & NagarHaveli
DamanDiu
Jharkhand
Chattisgarh % children 0-3 years below -2 SDWeight-for-Age, NCHS
≥ 50 %40-49 %30-39%20-29%
Malnutrition Map of India
HimachalPredesh
Nagaland
Source : National Family Health Survey-III 05-06 10
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Nutrition Situation in Gujarat
DLHS-2, 2002-04
• 45% U5 underweight• 50% Breastfed in 1st hr ***• 45% Exclusively breastfed **• 56% Initiate Complementary
feeding - 6-9 months ***• 24% Get adequate Proteins
& Calories*• 80% Anaemic (6-35 m)• 56% HHs use Iodized salt• 56% Vit A supplement**
NFHS 2005-2006* NNMB (ICMR)** DLHS – 2008***CES, Unicef - 2009
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Dept. of Food and Civil Supplies
-Iodized salt through PDS/ Mamta day-Fortified wheat flour & edible oil
Dept. of Education-Adolescent anemia control
- Mid-day Meal
Tribal DepartmentDoodh Sanjeevani
Yojna
Health Dept.- Vitamin A, IFA and Universal Salt
Iodization – Micronutrient Programs - State Nutrition Cell- Child Development and Nutrition Centers- Integrated Management of Neonatal and
Childhood Illness - Mamta Abhiyan,- Mamta Taruni
Rural Department-Sakhi Mandals
TSC & WASMODepartment
Provision of clean drinking water &
sanitation
DWCD-ICDS Universalization (Children under 6 years, adolescents girls, pregnant and lactating mothers),
-Energy dense Micro-nutrient Fortified Extruded Blended Food (Bal Bhog, Sukhadi, Sheera and Upma)
- IFA, Nutri-candy, Nutrition Counselling, Pre – School Education,
Gram Panchayat & Cooperatives-Kitchen Gardens
-Village Health and Sanitation Committees
Undernutrition is a Multi – sectoral Issue.Needs convergent actions by different Key Departments
12
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NUTRITION SERVICE NETWORK (HEALTH &FW)
State Nutrition cell-2008 Dept-H&FW
Tertiary Nutrition Rehabilitation centers
Child Development and Nutrition centers
District nutrition units
MAMTA Abhiyan13
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Structure of State Nutrition Cell
14
State Level District/Medical College Level
Block Level
• State Nodal Officer• Technical Consultant
Nutrition• Project Officer Nutrition - 2• Liaison Officer – Health &
ICDS• Admin Assistant• Finance Assistant• IDD Technical Officer• Statistical Assistant – IDD• M & E Assistant• Data Entry Operator• Lower Division Clerk - IDD• Office AttendantNational NutritionMonitoring Bureau• Assistant Research Scientist• Nutritionist• Social Worker
• Field Attendant
• Program Associate (26 districts)
• Nutritionist(6 Govt. Medical Colleges)
• Nutrition Assistant (68 CDNCs)• Cook cum Helper• Aya
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Nutrition Programs Under
State Nutrition Cell
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Nutrition Programs Under State Nutrition Cell
16
1. Health & Nutrition Day (MAMTA Abhiyan)
2. Adolescent Girls Anaemia Control Program (AGACP)
3. Iodine Deficiency Disorder Control Program (IDDCP)
4. Child Development Nutrition Centre (CDNC)
5. Nutrition Counseling and Rehabilitation Centre (NCRC)
6. Vit. “A” regular and Bi-annual Round
7. Gujarat Integrated Nutrition Program (GINP)
8. Mamta Taruni
9. IMNCI
10. School Health Program
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MAMTA ABHIYAN Mamta divas
(Health and Nutrition day) Mamta Mulakat
(Postnatal care visit) Mamta sandarbh
(Referral service) Mamta Nondh
(Record & register)
17
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MAMTA ABHIYAN
MAMTA DIVAS• H & N Day Once a month
• Immunization• Growth monitoring• Balbhog• Pregnancy testing• ANC/PNC• Iodized salt • Care of sick children
• Counseling• Promotion of Inst deliveries
MAMTA MULAKAT• PNC visits• 48 hrs Hosp stay• Vit.A • IFA/Calcium • IMNCI practice
MAMTA NONDH• MAMTA card• Registers• Service data• Review of data
MAMTA SANDARBH• Once a week Specialist clinic
• Drugs/Logistics
Social mobilization is critical for ensuring utilization of health and nutrition services
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Health Intervention-MAMTA Divas
Immunization: Children/Pregnant women Weighing of Children (0-3 yrs) & plotting on Mamta card IFA to Pregnant, Lactating & out of school Adolescent Girls 1.5 Kg iodised salt to Pregnant & actating women/month ANC (BP, HB, Urine examination, Folic Acid /Calcium tablets,
Physical examination etc) PNC (Calcium tablets, Vit A etc) Assessment of sick children using IMNCI protocol Counseling on Nutrition & Institutional Delivery Community growth monitoring
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Vitamin A supplementation Programme
Interventions for Micronutrient Malnutrition
20
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a Vitamin A Supplementation Programme
Interventions for Micronutrient Malnutrition
Vitamin A
Supplementation
Programme for
< 5 Children
Vitamin A
Supplementation
Programme for
Postnatal Mothers
21
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Feb.
Aug.
Routine immunization Biannual Round (Feb. & Aug.)
Dose 6
Dose 2 Dose 3 Dose 4 Dose 5
Dose 7 Dose 8 Dose 9
To Obtain high coverage Gujarat adopted Biannual Round Strategy
Vitamin A supplementation Programme may be the single most cost effective child survival intervention .
9 months to 12 months
Dose 1
1 to 5 years
Interventions for Micronutrient Malnutrition
22
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Status of Vit. –A in GujaratChildren age 9 months and above recieved at least
one dose of Vitamin A Supplement
31.7
60.9
0
10
20
30
40
50
60
70
DLHS II DLHS III
Source: DLHS – 2002 and DLHS - 2007 23
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Anaemia Control Programme
Interventions for Micronutrient Malnutrition
24
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80.1
60.8
74.7
55.5
0
1020
30
4050
60
7080
90
Children < 3 years Pregnant w omen Married w omen 15-45 Adolescent Girls
%
Anaemia is characterized by a low level of Haemoglobin in the blood,which is essentialfor transport of Oxygen.
Prevalence of Anaemia in Gujarat ( NFHS III )
Iron Deficiency Anaemia affects 50% population in India
Interventions for Micronutrient Malnutrition
25
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Anaemia Control Programme
Interventions for Micronutrient Malnutrition
Children 1-5 years
Antenatal women &Post natal women
School going Adolescent Girls 12-18 years
One small IFAfor
100 days every Year.
One Large IFA once a week
in school
Non anaemic mothers1 IFA tablet per day
for 3 months
Anaemic mothersAs per
Anaemia Protocol
26
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Adolescent Girls Anaemia Control
Program (AGACP) in Gujarat (2005 Onwards)
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Adolescent Girls Anaemia Control Program (AGACP) in Gujarat
Goal: At least 20% reduction in the prevalence of anemia among adolescent girls.
Interventions: Since 2004, adolescent girls of secondary and higher secondary schools (Standard 8th to 12th) are given one tablet of IFA every Wednesday under supervision of teacher.
Out-of school adolescents in each village are being supplemented with IFA tablets on Mamta Diwas under Mamta Taruni Program (Through Health).
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1. Average no. of adolescent girls attending “Shala Vikash Sankul” every month (2010-11 upto Dec)
2. Average no. of adolescent girls consuming IFA tablets in front of teacher on Wednesday every month
3. Percent of adolescent girls consuming IFA tablets
13,10,864
11,87,402
90.6%
Adolescent Girls Anaemia Control Program (AGACP) in Gujarat
95.5
95.3
91.9 94
.4
92.3 95
.1
93.5
92.4
93.4
87.5
87.2
84.9
91.7
92.5
92.9 94.2
91.2 91
80.085.090.095.0
100.0
Apr May Jun Jul Aug Sept Oct Nov Dec2009-10 2010-11
Percent of Adolescent Girls Consumed IFA Tablets on every Wednesday under AGACP
Per
cent
Source :- Education Dept.
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Anemia controlHealth: IFA supply to ANC and PNC (98%) IFA course completion by ANC 30% State protocol of Anemia
management in ANC and Preschoolers
Interventions: IFA DOT Hb estimation by colour scale Adolescent anemia (MAMTA Taruni) Building up counseling skills IEC/BCC
WCD ICDS: Enhanced coverage Fortified supplement Qualitative content Iodised salt” distribution under PDS
68%
Civil supplies: Fortified wheat flour supply to antyoday
families (92%) Soya fortification
Forest: Drumstick plantation (76% target covered) Mechanism for making saragava available to
the poor families
Gram panchayat : Community kitchen garden(100%) Awareness and ownership
Co operatives; Vegetable banks (100% of the target societies) Dudh dan; shak dan and sukhdi vitran
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Iodine Deficiency Disorder Control Programme
Interventions for Micronutrient Malnutrition
31
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GoalHH consumption of adequately iodized salt is
scaled up to 80%
Interventions Iodized salt promotion campaigns 1.5 kg iodized salt distribution to all pregnant and
lactating women through Mamta Diwas Salt testing is being done at grass root level by Female
Health worker Six regional IDD monitoring laboratories established in
six government Medical College Regular IDD surveys by Government Medical Colleges Advocacy and sensitization of salt producers for adequate
iodization. Awareness programme in schools
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Interventions for Micronutrient Malnutrition
The effect of Iodine deficiency is Most critical
during Pregnancy and Childhood. It could result in :
• Abortion• Still Birth• Birth of Mentally Retarded babies
Goiter
• Goiter• Dwarfism• Deaf –mutism• Squint• Neuro motor disorders
These disorders can be prevented easily before they occur.
The simplest method to prevent disorders of Iodine deficiency, is to consume Iodated Salt daily.This is the most effective and inexpensive intervention to prevent IDD
Iodine is an essential micronutrient. Required for normal body growth and mental development.
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Status of Adequate Iodized Salt Consumption in Gujarat
0 ppm19%
< 15 ppm15%
> 15 ppm66%
NFHS -3, 2005 IDD Survey 200934
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Status of Iodised Salt Consumption and Achievement of NIDDCP
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CHILD DEVELOPMENT NUTRITION CENTRE (CDNC)
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Objective
37
To provide treatment and nutritional care to the severely malnourished children
To ensure adequate nutritional supplementation under the guidance of a nutritionist
To arrest the number of Growth Faulters and Growth Defaulters (GF/GD)
Capacity building of mothers on IYCF (infant and young child feeding practices) and child feeding and training on preparation of low cost nutritious diet
Activities Severely malnourished (Red Zone) children admitted who were identified on
Mamta Diwas and from Village meeting conducted by village team Children are given nutrition rich food under guidance of
nutritionist, medicines for identified diseases and infection Diet is modified according to child age and health Mothers counseled on various topics of Health &Nutrition
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Status of CDNCs Year 2010-11 and 2011-12(1st Quarter)
ParticularsYear 2010-11
(up to Mar’11)Year 2011-12 (Apr to June)
Districts 18/20 19/20
Functional CDNCs 67/73 68/73
Reporting CDNCs 60 63
Population covering under CDNCs 1,47,36,926 1,53,84,949
Village meetings Organized/Planned 3327/4311 1239/1628
AWCs covered in village meetings 5208 1701
Children weighed 1,56,436 55282
Particulars Year 2010-11(up to Mar’11) Year 2011-12 (Apr & June)
Children found in Red Zone 28082 (18.0%) 9578(17.3%)SMCs admitted 10867 (38.7%) 4633(48.4%)
SMCs completed 10 days 10320 (95.0%) 4409(95.2%)
SMCs drop-out 547 (5.0%) 224(4.8%)
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5/30/2013 39
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Gujarat Integrated Nutrition Project
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Gujarat Integrated Nutrition Project
For effective implementation of Inj. Iron sucrose therapy in severe anemia cases trainingworkshops were conducted at Surat, Vadodra and Ahmedabad Medical colleges to cover 12tribal districts in 3RDD regions.
RDDs, CDHOs, CDMOs, RCHOs, Gynecologist, Superintendents of CHCs, District Hospitals(DH), Sub District Hospitals (SDH) participated in that workshop.
Though inj. Iron Sucrose have not been provided through State, purchases are being madethrough RKS and other sources and in that way, activities have been started at many of theplaces.
An amount of 2.32 crores has also been released for expenditure on1)Transportation and wage loss to mothers (Rs. 50+Rs. 50) for average 10 visits2) Lab. investigation and consumables needed for severe anemia treatment through respectiveRDDs.
Purchasing of Inj. Iron sucrose is in under process whereas acceptance of tender forhaematological analyzers have been made.
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Gujarat Integrated Nutrition Project Suggested Interventions
Universal screening and Hb. estimation of pregnant and Breast feeding women, adolescent girls by automated haematology analyzers in 12 tribal districts
Universal Screening of the children in the age group 0- 5 years by palmer-pallor method
Severe Anemia Treatment with intra venous injection of Iron sucrose complex.
Convergence of the Health and the WCD Department
74.5
46.3 47.4
80.1
55.560.8
0
10
20
30
40
50
60
70
80
90
100
Children (6-35m) Ever married woman(15-45yrs)
Pregnant women
NFHS II NFHS III
ANEMIA PREVALENCE RATE IN GUJARAT
GINP
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Mamta Taruni AbhiyanGujarat
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Programmes for Adolescents in the State 1. Adolescent Friendly Health Service 2. MAMTA Taruni Abhiyan 3. Promotion of Menstrual Hygiene4. Scheme for Empowerment of Adolescent Girls (SABLA)5. Adolescent Girl’s Anemia control Programme6. School health program7. Sickle Cell Anaemia/Thalesemia control program8. ICTC/PPTCT
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Purpose of Mamta Taruni Programme Special intervention for out-of-school girls aged 10 to 19 years, who
are always excluded from health services. Also girls enrolled in school but not attending school are provided services.
To meet the special needs in health, nutrition, and life skill development.
In 2009-10, 9 districts namely:- Dahod, Tapi, Banaskantha, Panchmahal,Narmada,Sabarkantha,Bharuch,Vadodara, and Dang were covered on pilot basis.
In 2010-11 the scheme was implemented in all 26 districts of Gujarat.
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Roles of Health and ICDS Functionaries on
Mamta Taruni AbhiyanFHW AWW ASHA PE Calculation of
BMI. Maintenance of records TT Immunisation, Hb.estimation IFA supplementation to adolescent girl
Registration of Kishori
Measurement weight and Height Purak poshan
Mobilisation of adolescent girls
Monitoring the consumption of
IFA tablets during home visits
Providing leadership to the group. Life Skill Education through Hum Tum Module. Coordination with stakeholders.
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ICDS Nutrition Programs1. Kishori Shakti Yojana: To improve the nutritional, health and development
status of adolescent girls, promote awareness of health, hygiene, nutrition andfamily care.
2. SABLA: It aims at empowering adolescent girls of 11-18 years by improvingtheir nutritional and health status, upgradation of home skills, life skills andvocational skills.
3. Annaprashan Divas : Celebration of Annaprashan in AWC on Fourth Fridayof every month to improve complementary feeding practices.
4. Ready to cook Take Home Ration specific to needs of children under 6years of age, pregnant, lactating mothers and adolescent girls (BalBhog, Sukhadi, Sheera, Upma)
Cont.
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ICDS Nutrition Programs5. Decentralisation: Fruit, Milk and Breakfast distribution through
Matrumandals / SHGs
6. Growth Monitoring: Children below the age of three years of age are weighedonce a month and children 3-6 years of age are weighed quarterly. Weight-for-age growth cards are maintained for all children below six years.
7. Nutrition and Health Education (NHED): BCC (Behaviour ChangeCommunication) strategy in the age group of 15-45 years – about their ownhealth, nutrition and development needs as well as that of their children andfamilies.
8. Indira Gandhi Matritva Sahyog Yojana (IGMSY) - A Conditional Maternity Benefit Scheme: Encourages the women to follow (optimal) IYCF practices including early and exclusive breast feeding for the first six months. Contributes to better enabling environment by providing cash incentives for improved health and nutrition to pregnant and lactating mothers.
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Nutrition related Training
in Child Health
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Nutrition related Training achievementsin Child Health up to July,2011
Name of Trainings Achievement up to July, 2011
Cumulative Achievement-Since Inception
Since Year
IMNCI 331-MO5719 FHW/
AWW
1695-MO38067 FHW/AWW
----------------Total - 39762
2005-06
NSSK 1058-MO5760-FHW/SN
1058-MO5760-FHW/SN----------------Total - 6818
2010-11
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IMNCI/F-IMNCI/ NSSK : Not just a training package but Nutritional Intervention
Implementation
Supervision & Monitoring
Training
Advocacy
Documentation
Child health Trainings boost Nutritional Behavioral Change in Communities.
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Dr.P.D.Vaishnav, Associate Professor, SIHFW, Gandhingar 52
IMNCI-Gujarat
IMNCI
Diarrhea
ARI
Conselling: BF,CF, immuni
zation
Fever/ measles/malaria
Malnutrition/ Anemia
Newborn & YI
0-2mo
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Dr.P.D.Vaishnav,AssociateProfessor,SIHFW,Gandhinagar 53
Conclusion“Many things we need can wait.
The Child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer “Tomorrow”. His name is “Today”.”
- Gabriela Mistral -
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Thank You..
5/30/2013 54