1 Introductory

Who is a child ? reasons for giving loving care to children, l A child is a growing person. Thus the there are more compelling reasons why child Pediatric age group includes boys and health is a top priority. These are listed below: girls till they complete their growth and l Children below 18 years form more this occurs at approximately 16 years than half of India's population in girls and 18 years in boys. Pediatrics Therefore the mere force of numbers therefore deals with this early and demands attention and investment in sensitive period of growing years. terms of financial allocations. l A child should not be considered a l Growing children are more vulnerable small or compressed adult. All that to sickness and death than the adult applies to the adult does not population, particularly in automatically apply to the child on a underdeveloped and developing smaller scale. countries. l The differences are both quantitative l Children are said to be an economic as well as qualitative, and are : resource to the country and therefore v In body structure no country can afford to ignore this v In function important human resource. v In response to disease l There are many diseases in childhood v In response to medication. which, if not detected and treated These differences are discussed promptly in childhood can result in elsewhere in this book. increased sickness, poor quality of life Definition of age groups and diminished longevity in adulthood. Therefore health care and The newborn differs from the infant, prompt treatment given to ensure good the infant from a toddler, a toddler from a health in childhood automatically school child and the school child from the ensures normal healthy adulthood, adolescent. Conventionally, children are grouped into the following age groups on proving the adage that "Pediatrics is the basis of differences and peculiarities in Preventive Medicine" their growth and development after birth. Hence, whatever the reason, children are a priority to any nation. Greater the care Why is child care a priority ? and attention given to them in terms of their Apart from the mere sentimental welfare, more prosperous and developed is

PREGNANCY 1ST BIRTH TO BIRTH TO 1ST 5 TO 12 TO 16 GIRLS 28th Week 7 DAYS 28 DAYS 12MONTHS 5 YRS 12 YRS 12 TO 18 BOYS EMBRYO PERINATAL NEONATE INFANT PRE- SCHOOL ADOLESCENT & & FETUS PERIOD SCHOOLER CHILD SCHOOL CHILD that nation. Given below are some As a consequence of these population facts that underline the priority disadvantages, these populations suffer from that is due to children and the vulnerable higher rates of sickness (Morbidity) and population that includes mothers in the death (Mortality) and these are shown in the child bearing age. tables given below. Morbidity and Mortality Age group Approximate or Proportion of Certain commonly used parameters Parameter population that give a measure of sickness and death in a community are defined below: Less than 1 year 3 per cent l Morbidity: Relates to illness. 1 to 3 years 6 per cent l Mortality: Relates to deaths 3 to 6 years 8 per cent l Morbidity rate: Number of people sick Total 1 to 6 yeas 17 per cent or disabled in a defined population per unit population per year. May relate to Children below 14 yrs 40 per cent area, age groups, sex, and community. Mothers 15-44 yrs. 22 per cent l Mortality rate: This relates to number Child bearing age of deaths in a defined population per Total Vulnerable population 62 per cent unit population per year. May relate to age, sex, area, community, also in Current scenario in disadvantaged relation to disease, communities: l Incidence of a disease: Number of Major proportions of populations of people falling sick in a given period of developing countries suffer from certain time in a given population. For disadvantages. These make them vulnerable example Incidence of Polio means how to higher rates of disease and death. many new cases appear every year. It does not include the cases already These disadvantages are: affected in previous years. l Large populations from high birth l Prevalence of a disease: Number of rates. people ill from a disease at any one l Poverty: among families, regions and point of time in a given population. states. For example prevalence of polio l Lack of education means how many cases of polio can be counted at one time in a given l Nutritional deficiencies community. It includes old cases that l Higher rates of infections from may already be afflicted with polio crowding and poor hygiene plus the new ones that may be present l Poor transport facilities in rural areas at the time of a survey. l Poor outreach of educational and For mortality rate see table below health services

2 Selected rates by country for crude For the sake of measuring health care birth rates, infant mortality rates and of the population in general and children in under-five mortality rates (2007) particular, terms in common use, their definition and significance are given in the Crude IMR Under-five table (see below): Country birth per mortality rate per 1000 rate per Rights of the Child 1000 live 1000 live popu births births With progress and awakening of lation people, awareness of the needs and rights of children and women has been appreciated. India 23 54 72 International organizations like the WHO, Pakistan 27 73 90 UNICEF and others have established targets Bangladesh 25 47 61 for their health and welfare. Each nation has Thailand 15 6 7 its own programs and constitution designed to promote health of children. Sri Lanka 15 17 21 China 13 19 22 United Nation's declaration of the Switzerland 9 4 5 rights of the child: UK 12 5 6 The declaration of the rights of the USA 14 7 8 child was adopted by the General Assembly of the United Nations, on 20th November Singapore 8 2 3 1959. These are: Japan 8 3 4 1. Right to develop in an atmosphere of

TERM USED DEFINITION SIGNIFICANCE

Infant Mortality Number of deaths under age I year Indicates health status of a community, Rate (IMR) per thousand live births in a defined particularly efficiency of perinatal community services. Under Five Number of deaths under 5 years in a Reflects health services for children in Mortality Rate given year, per thousand live births the community, especially related to newborn care, immunization, nutrition, medical & health services. Maternal Mortality Total number of deaths in women at Measures risk of women dying from Rate child birth or within 42 days during a causes at labor and therefore reflects given year per thousand live births in socioeconomic, obstetric and related a defined community health status Neonatal Mortality Number of deaths during first 28 days Reflects deaths from low birth weight Rate per thousand live births in a year and congenital disorders (internal causes). Reflects care in antenatal period and labor. Post neonatal Deaths between age 28 days and I Unlike Neonatal, Post-neonatal Mortality Rate year per thousand total live births mortality indicates deaths from external during the given year causes

3 affection and security and wherever children below the age of 14 years in possible, in the care and under the factories responsibility of parents l Article 39: prevents abuse of children 2. Right to enjoy benefits of social of tender age security, including nutrition, housing l Article 45: provides for free and and medical care. compulsory education for all children 3. Right to free education until they complete the age of 14 4. Right to full opportunity for play and years. recreation National Policy for children 5. Right to a name and nationality In August 1974, the Government of 6. Right to special care if handicapped India adopted a National Policy for Children 7. Right to be among the first to receive which declares: protection and relief in times of "It shall be the policy of the State to disaster. provide adequate services to children, both 8. Right to learn to be a useful member before and after birth and through the period of society and to develop in a healthy of growth, to ensure their full physical, and normal manner and in conditions mental and social development. The State of freedom and dignity shall progressively increase the scope of such 9. Right to be brought up in a spirit of services so that within a reasonable time, all understanding, tolerance, friendship children in the country enjoy optimum among people, peace and universal conditions for their balanced growth" brotherhood Universal Children's day: 10. Right to enjoy these rights regardless of race, color, sex religion, national or In 1954, November 14 was designated social origin. as "universal children's day" by the UN general assembly assigning to UNICEF the Relevant articles in the Constitution responsibility of organizing celebrations on of India: the day for promotion of child care. l Article 24: prohibits employment of

4 Who is a good Pediatrician? l Knowledge is acquired from books, Children need 'tender loving care'. Let lectures, discussions and so on. us call it 'TLC' which should be the central l Skills can be learnt in stages, e.g., first object of caring for children both well and by reading instructions of a particular sick. Well children need attention for procedure then watching the ensuring continued, illness-free growth techniques being carried out by through monitoring and charting growth experienced teachers and senior periodically, immunization and education to colleagues, and finally carrying it out mothers. Sick children need support and under supervision before finally doing professional care during the illness The it independently. Pediatrician is thus an educator, provider of l The third and the most difficult aspect care in health and illness and most of all a i.e. attitudes can neither be learnt nor friend to the family, all rolled into one. He/ developed from books nor by She needs to be sensitive to all such needs instructions. They are learnt by and more. Thus a good Pediatrician should working with professionals, by not only be a 'good human being' but a little carefully watching them in varying more: situations keeping the mind's eye l He/She must love children. open. The saying that 'actions speak l louder than words' aptly defines the He/She should be kind, honest, gentle, quality of a good teacher who by soft spoken and patient, to parents and actions can consciously and their tiny patients, avoiding being subconsciously teach a student more brusque in spite of heavy service than by any number of words, lectures commitments. or instructions. l His/Her skills of communication should be good and effective and Multiple roles of a Pediatrician: continue to sharpen with experience. Not only are the natures of nurses' l A Pediatrician never works alone. He/ roles multiple but also vary: She should be adept at working in a - Health care (Social worker, educator) team in an atmosphere of cooperation. - Curative: Primary, secondary or l He/She should be professionally tertiary hospitals care. competent in the the care of children - Superspeciality care. in routine day to day as well as critical, care. - Teaching l His/Her professional skills should not - Work for research organizations only be adequate but also continue to - Advocacy for the care and welfare of sharpen and mature with experience children in different forums. through continued education. Learning: Learning in any technical profession, like that of a doctor or nurse, includes three aspects: 'Knowledge', 'skills' and 'attitudes'.

5 How is a Child 2 Different from an Adult

In size, proportions, shape and rate of growth Not only is overall size different compared to the adult, the body proportions are also different at different ages. Fig. 1 shows that in a newborn the head is quite large compared to the rest of the body. It comprises one fourth of the 2 mo. (fetal) 5 mo. Newborn 2 yr. 6 yr. 12 yr. 25 yr. total body length and the centre of the Fig. 1 : Body proportions from newborn's body is at the umbilicus. There is before birth to adulthood very short neck in a baby and it appears Below 7 years: The span is 3 cms shorter that the head is directly sitting on the upper than the height part of the chest. As the child grows, the 8-12 years: Span and height are equal centre of the body shifts downwards and by After 14 years: In boys: span is 4 cms adulthood it is at the pubic symphysis so more than the height that sitting height is equal to limb length. In girls: span is 1 cm. The sequence of growth is that after the more than the height. skull, the trunk grows and still later at puberty, limbs grow fastest. Shape: l Comparing the arm span (total length Infants below 1 year have round of the outstretched hands from middle finger contours and they appear plump. As infants grow, their fat tissue is replaced tip of one hand to middle finger tip of the by muscle and eventually their other) with the total height the following contours become less rounded and changes occur with age: (Fig. 2) more linear.

SPAN

HEIGHT

Fig. 2 : Height, span, crown-rump (sitting height) and rump-heel measurements l Girls at all ages retain more fat than l The endocrine (reproductive) growth boys. During puberty their hips are curve is almost opposite of brain broader growth. These organs grow slowly till l Boys are more muscular and have before puberty and then show a heavier bones. During puberty, boys sudden, large spurt making all the have broader shoulders. difference between a child and adult and between a man and woman. Rate of growth: As children grow not all systems and organs grow at the same This differential growth pattern has rate. A look at the following growth curves considerable clinical significance in terms of shows how some organs and systems grow understanding signs, symptoms, etiology at rates different from others at different age and management of disease at different age periods. (Fig. 3) periods. This will become evident as you l learn and observe children in health and in The earliest to grow is the brain and disease. the skull. At birth the brain is 25 % of the adult, by 5 years it is 90 % and by Systemic differences 10 years about 95 % so that there is The essential anatomic and very little growth left to occur after that. physiologic differences between children l The lymphoid tissue comprising the and adults make children particularly thymus, adenoids, tonsils and lymph susceptible to certain conditions. nodes etc, show a big peak just before adolescence, almost twice adult size and The Gastrointestinal tract: then shrink to adult size by 20 years. l The newborn infant is equipped with the ability to suck and swallow to 200 enable him to feed itself but initially LYMPHOID TYPE this is only a reflex action. With growth 180 and maturing of the nervous system, 160 sucking and swallowing become more voluntary, saliva increases and as milk 140 teeth also appear, the baby can chew. l The junction of the lower end of the AGE 120 esophagus and the stomach (the NEURAL TYPE cardiac sphincter) is relaxed. As a 100

PERCENT result babies vomit easily with

80 contraction of the stomach during peristalsis. 60 l GENERAL TYPE The emptying time of the stomach is shorter in newborns and young infants 40 so that it empties quickly necessitating smaller, more frequent feeds. 20 GENITAL TYPE l Due to the rapid peristalsis of the gut 0 in infants, its functional and 0 4 8 12 16 20 immunologic immaturity and liquid Fig. 3 : Curves showing differential diet, they tend to pass loose stools. As growth rate of systems

7 intestinal mucosal immunity and Respiratory system: enzymatic action of digestive juices l The fetal lung is filled with fluid, has mature and solid food is introduced, hardly any respiratory function but there is change in gut flora resulting in expands suddenly after birth as a solid stools as in adults. result of: l The liver is proportionately large in (a) lack of oxygen level (with high newborns and infants and therefore CO2, high PCO2 and low pH, i.e. easily palpable on abdominal acidic pH); examination. As they grow, the increasing space under the diaphragm (b) cold room air; permits the liver to occupy available (c) handling of the baby and, space and eventually becomes (d) downward push of the impalpable. diaphragm that causes negative l The functions of the liver, intrathoracic pressure and Among others is iron storage, secretion suction of the air into the lungs. of bile, storage of sugar in the form of l A substance called surfactant that lines glycogen and its release as required, the air passages maintains the surface storage of protein, of fat soluble tension in the passages and does not vitamins like A, D and K and let them collapse as air enters into the formation of fat. Younger the children lungs with the first breath. more immature are these functions. l The fluid in the lungs is carried away by For instance: anemia of infancy occurs the lymph vessels and blood capillaries as a result of poor storage of iron, so that normal breathing ensues. particularly in a premature baby. l A newborn's external auditory meatus Tendency to develop hypoglycemia is short and straight and so is the results from inadequate ability to store Eustachian tube so that infection from and release glucose from glycogen. the ear or throat can easily be carried Protein calorie malnutrition can result from the throat downwards into the from lack of storage of protein from lungs. low protein diet. l The tonsils and adenoids (lymphatic l The Pancreas produces the three tissue) are large and are subject to important digestive enzymes- starch repeated infection in young children. splitting (amylase), protein digesting l The air passages are small and the (trypsin) and fat splitting (lipase). With immaturity of their structure and maturity and ingestion of food all function are such that cough reflex is these become available, especially not strong enough as in the older child lactase which is important for splitting and adult and therefore secretions in lactose (milk sugar) in breast milk and young infants are not expelled easily. cow's milk. These are removed eventually either l The mucosal cells producing lactase in with vomiting or swallowing. the gut are susceptible to damage from The skin: infection resulting in milk sugar l (lactose) intolerance and diarrhea. The skin is responsible for maintaining

8 temperature of the body at normal. It form of pimples and blackheads is does this with the help of sweat more common during the adolescent glands. The sweat produced causes years. evaporation and brings down temperature. The heart and blood vessels: l l The skin is also responsible for During fetal life the function of protection against infection by oxygenating blood is carried out by providing a barrier to the germs that the placenta since the lungs are threaten to enter the body. nonfunctioning. Blood from the heart goes to the placenta and returns to the l There are two kinds of sweat glands- heart after oxygenation from the eccrine and apocrine. Eccrine glands placenta. are present in the skin all over the l body and produce sweat for With the first breath at birth, the fetal temperature regulations. Apocrine circulation changes over to the adult glands appear just before puberty, type because the lungs open up and around armpits, umbilicus and genital the impure (venous) blood from the area and are fully developed by heart, (instead of the placenta) now adolescence, resulting in the goes to the lungs for purification and characteristic odor in adolescents. the pure blood also returns to the heart for circulation. The ductus l Apart from sweat glands there are arteriosus which was open (patent) sebaceous glands in the skin that now closes as it is no longer required produce sebum. The cheesy protective to by-pass the lungs. If patency of the layer of skin in the newborn is ductus persists, i.e. if it does not close, produced by these glands and is called it can cause problems. vernix caseosa. During puberty and l adolescence, their secretions are Many kinds of sounds can sometimes responsible for the typical 'pimples' be heard in the heart on auscultation in (acne) over the facial skin and 'black the normal newborn but most of these heads' over the nose. disappear soon and should not be mistaken for congenital heart defect. l The fat layer of the skin varies with However a close follow up is necessary age. In infants, it gives the baby a by an expert to confirm all is well. 'plump' look which reduces gradually l and is replaced by muscle as the child The heart rate in babies is high and grows. Girls have more fat all along diminishes with age. At birth it is upto than boys which is responsible for the 140 per minute. Sinus arrhythmia, that round contours of the female, is irregular heart rate with respiration, especially around the hips, thighs and is normal in children. This is most chest. apparent on auscultation during sleep. For rates of heart and respiration one l Diseases of the skin depend on the should look up tables that give rates at varying anatomy and physiology of different ages. (See section 1 chapter 6, the skin. A newborn's skin is subject to table on p. 61 under 'General physical blister like (bullous) lesions. An infant's examination') skin is more prone to seborrheic l lesions over the scalp etc. Acne in the Similarly, variations of blood pressure

9 also occur, more in infancy because of (excess sodium in the fluid spaces) varying physical activity. causing fluid retention and edema. l Some degree of temperature control is l Recovery from acute renal failure in a also carried out by blood capillaries by young infant is more likely and more contracting when it is cold, thus prompt than in an adult because of the conserving heat and dilating to allow ability of regeneration of functioning heat loss when it is hot. cells of the kidney. l The heart is more horizontally placed The Central Nervous System: in the young child and becomes l vertical and rotates gradually with age. The brain size grows very rapidly and as shown in the graph (Fig. 3) almost The kidneys: doubles its size by the first year. At l The kidneys are lobulated at birth and birth the brain is 25 % of the adult, by gradually assume adult shape. 5 years it is 90 % and by 10 years about 95 %. l The bladder is essentially an l abdominal organ and descends into The sulci of the cortex increase in the pelvis as the latter becomes number and get deeper during the first roomier. few years. l l The prepuce of a male baby is not Myelin sheaths cover nerves retractile and parents may feel it is increasingly and this maturation phimosed. process is called myelination. With this l increasing activity nerve functions Any congenital anomaly or obstruction mature so that a baby is able to make to the flow of urine can result in increasing and finer movements from repeated urinary infection. There are the earlier immature and gross no symptoms the baby or a toddler movements. (See behavioral growth in may complain. In such a situation, the chapter on growth and early diagnosis is possible only development). through repeated examination of the l urine in suspicious complaints like A baby at birth is endowed with certain vomiting, unexplained fever, failure to primitive but protective 'neonatal thrive. If diagnosis is missed, repeated reflexes' like sucking, Moro's, rooting, infection can ultimately cause kidney grasp etc that enable him to seek the damage over a period of time thus mother's breast and mouth the nipple, reducing life span and adversely suck and swallow and grasp objects influencing quality of life from chronic reflexly. Later these activities become sickness. voluntary as they mature. l l Kidney function is almost as in an Increasing stimulation in the form of adult by the first year of life but the mother's touch, hearing, vision, taste capacity to concentrate urine is poorer and smell enable a baby to appreciate so that as a result of poor acidification sound, speech, color, shape and feel of urine, acidemia is more likely. his immediate environment and Because of poor sodium reabsorption gradually enable him to learn to in the newborn, excess salt cannot be respond to these with increasing handled, resulting in hypernatremia maturity. 10 Some important milestones of Parathyroid, Suprarenal (adrenals) and maturing of vision and hearing are: Islet cells of the Pancreas. The Vision: Newborn: barely able to see reproductive glands include the beyond 6 inches ovaries in females and the testes in males. The regulation of growth during At 9 Beginning depth infancy, childhood and adolescence is months: perception of vision, mainly directed by the pituitary growth formation of images hormone, thyroid, insulin and the At 3-12 Maturing gonadotrophic hormones. months: development of eye l The Pituitary gland is considered 'the muscles with fixation bandmaster of the endocrine orchestra' of objects - focus. as it controls other endocrine glands. It At 6 years: Maturity of vision, has an anterior and a posterior lobe. integration/ v The anterior lobe secretes the recognition of images. growth hormone (GH) also Visual acuity 20/20. called the somatotrophic At 8-12 Some degree of hormone (ST), which is years: myopia (short responsible for growth. Its excess sightedness) causes gigantism and deficiency Hearing: Newborn: Able to hear loud causes short stature (dwarfism). noises and startle in Levels of this hormone in the response blood are high during fetal life and during puberty and these 2 months: Can hear soft sounds. high levels are responsible for Increasing ability to two growth spurts- one during locate direction of fetal life and the other at puberty sound after 2nd till growth is complete. month. v The posterior lobe of the 6 years Hears well and pituitary gland secretes the onwards: understands; able to antidiuretic hormone (ADH) also imitate words and to called vasopressin. As the name respond to speech, suggests, it inhibits diuresis gradually maturing (water secretion) from the kidney to adult levels. tubules holding back water. It is Endocrine and reproductive system. deficient during the first year; and results in the infant passing l A look at the graph (Fig. 3) shows how dilute urine. The pituitary also slow development of reproductive secretes prolactin and oxytocin, glands, and consequently their but their levels are stationery function is, till before puberty and how during childhood and therefore the spurt during puberty is responsible of not much significance at this for the rapid reproductive growth at age. Besides these hormones the adolescence, resulting in transforming pituitary also secretes certain a child into an adult! The endocrine 'stimulating/trophic hormones' glands include the Pituitary, Thyroid, that respond to deficiency of and 11 control other endocrine glands substantial role in physical growth (thyroid, adrenal etc) hence the together with pituitary growth name "bandmaster of the hormone, thyroid and gonadotrophic endocrine orchestra". hormones as stated earlier. Glucagon, l The thyroid hormone, thyroxine, is an also secreted by the pancreas has important hormone that has profound similar action. Insulin is responsible for effect on several functions that include glucose regulation and with increase in body growth and metabolism, skeletal blood glucose islet cells increase the growth and mental development. secretion of insulin to metabolize the Under the influence of the pituitary excess glucose. Thus, in a pregnant (thyroid stimulating hormone) it mother who is diabetic, her promotes fetal growth and continues hyperglycemia can stimulate the fetal to do so during infancy, childhood and pancreas to produce insulin which adolescence. Its deficiency produces after birth, being in excess of the 'hypothyroidism. This is responsible for baby's requirements, results in failure in mental and physical growth, hypoglycemia and may result in in addition to other physical signs and convulsions. symptoms. l The ovaries in the female and testes in l The suprarenal (adrenal) glands the male produce Estrogens and secrete several hormones from the Testosterone respectively under the medulla and the cortex. Those from influence of the Pituitary the cortex include aldosterone and gonadotrophic hormone. They are deoxycorticosterone that influence almost dormant until before puberty metabolism of water and electrolytes, and increase in activity after that. (sodium and potassium). The v In girls, the ovaries look like that hormones produced by adrenal of an adolescent by 11 - 12 years medulla are adrenaline and but they begin ovulating by 12 - noradrenaline. The size of the adrenal 13 years. Inadequate glands is large in the 2 month fetus, development can cause delay in almost twice the size of the kidney, but puberty and excess may result in diminishes by birth so that kidneys are precocious puberty. larger. The function of the adrenals is v In boys size of testes begins to minimal in early infancy but gradually increase between 10 and 13 increases by puberty. years and is complete between l The Parathyroid glands secrete 13 and 17 years. Size of testes parathormone. Together with vitamin can be measured with the help of D it regulates calcium metabolism. The a series of plastic balls of level of parathormone increases with different sizes and this simple drop in serum calcium. equipment is called "test size" Hypocalcaemia in the newborn is said (see elsewhere in the chapter on to be related to functional immaturity growth and development). of parathormone at this period. Water and electrolytes l The Islet cells of the pancreas produce insulin which is a hormone and plays a Water is an important constituent of

12 the body and this is more significant in children as a proportion of body weight children. Essential electrolytes (solids) than in adults. The extra cellular water also include sodium, potassium, magnesium, diminishes with age but the intracellular chloride, bicarbonate and phosphate in water shows mild variations. addition to protein. Both water and The table below gives the solid content electrolytes occupy certain 'compartments' (electrolytes) of various compartments: in the body and these three compartments It clearly shows that among cations include the blood vessels that contain blood Potassium and magnesium are the main (the vascular compartment), the cells of the electrolytes within the cell. body (intracellular compartment) and the spaces between the cells (the interstitial mEq/L mEq/L mEq/Kg compartment). A balance of water and water electrolytes is maintained within these Electrolyte Plasma Interstitial Intracellular compartments in normal conditions. In abnormal situations major shifts in water or Sodium 140 143 +- 10 electrolytes may occur between Potassium 4 4 160 compartments which can cause serious Calcium 5 3.3 disorders. There are considerable differences Magnesium 2 26 between adults and children in the TOTAL distribution of fluids and electrolytes. The CATIONS 151 table below gives the normal values of water Chloride 104 114 +-2 at different ages and in adults. Bicarbonate 25 29 +-8 Age Total Extra Intra Phosphate 2 95 water cellular cellular Sulfate 1 20 water water Organic Acids 6 (as % (as % (as % Protein 13 55 body Wt) body Wt) body Wt) TOTAL ANIONS 151 At birth 79 44 35 6-12 months 60.4 27.4 33 Of anions, Chloride and Bicarbonate 1-3 years 63.5 26.7 36.8 are the major electrolytes between cells and 3-5 years 62.2 21.4 40.8 Phosphate and Protein within the cells. Physiologic processes in the body maintain 5-10 years 61.5 22 39.5 the anions and cat ions at the same total 10-16 years 58 18.7 39.3 (151 mEq/L) in the plasma, thus keeping the Adult 60 20 40 acid base and water/electrolyte in balance. The disturbance of this balance has severe As seen from this table the total body consequences in terms of sickness and water is greater in younger infants and survival.

13 3 Growth and Development

The two terms are used nervous system. For example a baby, interchangeably. Growth refers to increase in when shown a balloon responds by number of cells and therefore size. moving his arms and indeed all his Development means maturation of function. body in excitement in an attempt to hold it but cannot do so. As the child Principles of growth and gains increasing skills of hand development manipulation during play and other Both occur together and follow certain activities finer movements develop rules: involving eye hand coordination like 1. Growth occurs in a sequence and is threading a bead or threading a not haphazard. One step is followed needle. by a more mature step and so on. That Factors affecting growth: is, a child first learns to sit and then Two major factors that determine stand and later walks, in that growth are nature and nurture. Nature is sequence. what the child inherits from its parents that 2. Although it is sequential, the rate of is, what he is born with. For example tall growth may vary so that it is faster at parents usually bear tall children and color some stages than others. For example of the skin, eyes, and personality of a child growth is fastest during infancy and resemble those of their parents. Nurture, on then another spurt occurs at puberty. the other hand is the environment, that is, 3. Growth occurs from head to foot the manner in which a child is brought up. (cephalocaudal). That is, the head Good nutrition, caring parents, good grows faster first, then the trunk and schooling all depend upon parents' lastly the limbs. This can be seen as socioeconomic status and education. The large head and small legs of an infant period of intrauterine growth from as proportion of the body length and conception to birth, however, is an long legs of the adolescent and adult. overlapping period for both influences- 4. Growth and maturity occurs from the nature as well as nurture. While the fetus is trunk to the limbs (centrifugal). This developing genetic characters (nature) it is means that a baby first learns to move also influenced by maternal health, nutrition his shoulders and then his forearms and the length of gestation (nurture) during and finally acquires fine finger intrauterine life. The individual factors that movements enabling him to affect growth are now discussed below. manipulate objects in his hands. However, it must be appreciated that a child is subjected to multiple and overlapping 5. Larger and mass movements of early influences and no single factor is infancy that appear purposeless are responsible: gradually replaced by more fine and l deliberate movements with maturity Sex: Boys are normaly larger at and increasing myelination of the birth. They continue to be larger than girls till about 10 to 12 and overall upbringing than of years. Hereafter girls mature uneducated or undereducated faster till beginning of the families even if the financial pubertal spurt when boys again status is similar. take over and end up taller than l Culture and Society: Each girls. Bone age is more advanced society has its own language, in girls and permanent teeth religion, art, music, folk lore, appear in them earlier. In traditional beliefs and values. addition to these physiologic These determine practices, factors is the unfavorable attitude manner and perception of of certain societies towards a upbringing children, the nature of female child which has its own food consumed by that society impact on their survival and and so on. For example the growth. contrast seen between eastern l Race: Differences in various and western societies. races is well known. These l Climate and Season: Growth differences are in the form of in children is dependant on height, body proportions, color season and climate. For instance of skin, hair etc and are the result children grow taller in certain of inheritance in addition to the seasons and heavier in certain environment those races live in. others. This is determined by the l National and regional: How regional differences in the prosperous is the region, the climates between countries and form of governance , law and regions. order, distribution of resources, l Illness and disease: These are the racial mix in that region etc related to poor living conditions, all determine how children grow illiteracy, poverty, poor outreach in that region. of health services. They are often l Economic factors: As said, accompanied by prevalence of prosperity not only of a nation or endemic diseases like malaria a race, region or of a community and others like diarrhea, but also that of an individual respiratory diseases and family is important. Affordability malnutrition With each episode and availability of food and other of illness a child gets a set back essential needs have their in his growth. Longer the impact. Poverty never exists duration of illness greater is the alone but is often accompanied impact, particularly on weight. by poor education, sickness Height is less affected or disease and suboptimal living unaffected with brief illness but conditions can slow down with prolonged l Parental education: Children illness. of educated and therefore l Secular trends: It has been competent parents get a better observed that with passage of deal in terms of health, nutrition time changes occur in patterns of

15 growth. For instance, children are concept of 'percentiles': In preparing these now taller and heavier than those percentile charts thousands of normal, decades ago. Menarche in girls is healthy children, boys and girls have been occurring earlier. These measured at each age. These measurements nutritional trends are global and are then arranged in ascending or are believed to be due to descending order. Say, for example we have prosperity, improved health and a hundred normal children of a given sex, greater sociocultural stimulation say boys, aged exactly 5 years whose from coeducation, TV and heights are measured. Suppose we line up greater social interactions at these 100 normal boys with the shortest to home and outside. the left and the tallest to the right in order of ascending heights, the fifth from the left will Physical growth be termed as belonging to the '5th What is 'normal' growth? percentile' and the fifth from the right to the 95th percentile. Similarly the 50th child who Suppose a child is brought by the is exactly in the middle is said to be in the mother for a check up and the mother 50th percentile. Even though all are normal, wishes to know if her child is normal and a mother can be told that her child is in healthy. We need to have some yardsticks to such and such percentile which tells her determine if the child is growing as where her child stands within this normal expected. We therefore look for some range. All those below the fifth and above 'standard' or 'normal' charts/tables against the 95th are likely to be abnormal and need which we assess a given child. Normal is to be investigated for any abnormality. never a single mathematical figure; there is Since charts can get crowded with too many always a certain "range" of normality. The curves, conventionally only seven next question is how do we say what range representative percentiles curves are drawn is normal for a given child? Experts in the field have prepared charts after measuring a on these charts and these are the 5th, 10th, very large number of normal healthy 25th, 50th, 75th, 90th and 95th. In a children. There are internationally used normal healthy population, most children charts, like those prepared by the National are in the middle ranges on either side of Council of Health Statistics (NCHS) in USA the 50th centile (between 25th and 75th and WHO. Regional or national charts are centiles) and the numbers diminish on either also available e.g. those prepared by the side of the median 50th centile. Separate Indian Council of Medical Research (ICMR) charts are available for height, weight, head for India. No charts are applicable for ever. circumference and other measurements, for Socioeconomic changes, control of diseases boys and girls and for ages birth to 36 and improved health services necessitate months and between 2 and 18 years (See review and updating these charts. charts appendix I). Since "normal" is always a range and Example: Say a girl aged 24 months not a fixed mathematical figure, the is brought by her mother for check up and standard charts available indicate this range wishes to know if she is growing well. Her with the help of 'percentile curves'. (See weight is 12 kg. A look at the chart charts appendix I). These curves indicate (Appendix 1, p. 318) will show that she is in where (within this normal range) the child the 50th centile. The mother can be stands. It is important to understand this reassured and told that her baby is in the

16 median range for her age. If she weighs 9 hormonal. Short stature is either due to kg, then she falls below the 5th centile which nutritional causes or from skeletal or means she is underweight. If above 15.5 kg, endocrinal causes. she is overweight. Head Circumference: (Fig. 8) Physical growth measurements Reflects brain growth. Small size of brain is commonly used in clinical work include often due to congenital causes or anoxia at weight, height and head circumference. But birth. Premature closure of various sutures many more can be used for specific may result in abnormal shape of the skull purposes, such as arm circumference, sitting depending on which suture is closed. A height, span (i.e., measurement of the closed suture does not allow the brain to outstretched arms from middle finger tip of grow appropriately. A large skull most often one hand to the finger tip of the other arm), results from 'hydrocephalus' i.e., collection and ratio of sitting height to leg length, of CSF in ventricles etc, in large amounts termed "crown rump to rump heel ratio" due to obstruction in flow of circulation or (ratio of upper segment of body to lower or failure of absorption in the subarachnoid CR: RH ratio). (Fig. 2) Sometimes shoulder spaces. There are other less common width and hip width are taken in adolescent causes, mostly congenital. Head boys and girls. Size of testes is required in circumference should be routinely charted the assessment of boys during puberty and periodically on standard charts during this is done with the help of a series of infancy and preschool years to monitor rate plastic balls of different sizes labeled in cc's, of brain growth. It enables early diagnosis of beaded together in a thread and called 'Test certain disorders and prompts intervention Size'. (Fig. 10) Subcutaneous fat can be to prevent handicap in later life. measured with the help of skin fold calipers Midarm Circumference: (Fig. 9) Techniques of measurement are given Circumference taken in the middle of the separately (see below). In routine work upper arm in preschool children (under 5 however, all are not required. Measurements years) is a useful index of assessing are chosen as required. malnutrition in a community by social Clinical significance of Various workers to pick up malnourished children needing special care. The usefulness is measurements based on the fact that arm circumference Weight: Indicates the state of does not normally change between the nutrition and can fluctuate with sickness and beginning of the second year to the end of disease. Excessive weight indicates obesity the fifth year. If the arm circumference is less and poor weight may be the result of than12.5 cm, the child is malnourished; starvation. In the newborn it reflects state of above 13.5 cm is satisfactory. Since this is intrauterine growth. This is the most applicable to all children between 1 and 5 commonly used parameter in clinical work years it can be used without knowing the especially for periodic growth monitoring on precise age of the child and enables rapid growth charts and dosage calculation. identification of children in need of Height: Stature or height does not nutritional care. fluctuate much unless there is prolonged Sitting Height (Crown-Rump: CR) sickness. It reflects parental height. Height and Rump Heel (RH): The measurement beyond the normal range is suspicious of of the upper segment of the body (sitting certain disease conditions usually genetic or height or CR) and lower segment (or RH) 17 are useful in diagnosing certain disorders boards, weighing scales, tape etc. and by when the ratio is altered. Normally this ratio learning the techniques of precise is 1.7:1, at birth i.e., the upper segment is measurement. greater than the lower. As the child grows, Behavioral growth is assessed by the lower segment lengthens faster so that watching children's activities like turning, the ratio is 1:1 at puberty. Shorter limbs sitting, standing, walking, running, talking, than the trunk occur in hypothyroidism and and during play activities; by asking in skeletal dwarfism like achondroplasia questions from parents about performance (circus dwarfs) etc. These proportions are of activities and by the use of play for instance, unaltered in Pituitary dwarfism. equipment like building blocks, bell, Limb length is abnormally greater than the pictures, crayons etc. trunk in Klinefelter's syndrome. Hip and Shoulder Width: These Instruments and techniques measurements are useful during puberty. measuring physical growth: After puberty, shoulders are broader in boys 1. Weight: and hips in girls. The measurements have significance in genetic and hormonal The Instrument: A large variety of disorders. weighing scales are available for different purposes. For weighing small children, Testicular Size: (Fig. 10) It may be spring type measuring scales with a dial are necessary to assess a boy's pubertal growth reasonably good. Beam balance scales by measuring the size of his testes. The (Fig. 4) involve a lever on which a metal equipment is a simple one (See Page 21). piece slides balancing the lever rod. Weights Skin Fold Measurements: These are hung at the end of the lever to balance are carried out with the help of 'Skin folds Calipers'. The idea is to measure body fat. It is useful in assessing malnutrition and obesity and is of limited use in clinical work. Sliding Body Mass Index (BMI): This Weight distinguishes overweight from obesity and Beam indicates body mass in general. Body mass index is arrived at by this formula: Wt. in kg / Ht. in meters2 For example: a child weighs 40 kg and his height is 150 cm (i.e. 1.5 meters), his BMI will be: 40 / 1.52 (2.25) i.e. 17.7 Charts are available showing values that indicate normal, malnourished, over- Fig. 4 : The slide-beam scale weight and obese children. the rod giving the baby's weight. Electronic scales are very accurate but expensive. For Measurement of growth door to door weighing of children in the Physical growth like height, weight community or at the primary health center, circumferences etc, can be measured with (Fig. 5) a spring scale with a dial is used, the help of instruments such as measuring that has a hook which can be hung from a

18 door beam or a tree. A 2. Height or length: sling made from cloth or The instrument: Standing height is nylon to hold the child measured against a measuring board that is attached to the hook can be made to order. It can have a platform and the weight can be on which a child can stand, (Fig. 6) has a read from the dial. Bath vertical board on which a measuring scale is room scales are not fixed (metallic or non-stretchable fiberglass reliable especially for tape). A block of solid wood; preferably younger children as they triangular, placed against the vertical board are not accurate. For is used to place over the head, to measure older children, these can the height. For infants, who cannot stand, an be used provided the infantometer is used to enable measuring zero error is corrected length in the lying position (Fig. 7). It frequently. consists of a flat board marked in inches and The technique: centimeters or with a fiberglass tape fixed The weighing scale should be at eye level so that weighing is accurate. Zero error should be corrected each time a child is Fig. 5 : Weighing a weighed (this is called baby in a rural area 'taring'). The child should be barefoot and Fig. 6 : Measuring standing in his undergarments. Adolescent girls can height. Note that the occiput, wear a loose gown. The 'pan' or basket of shoulders, buttocks and the the baby weighing scale should be kept heels should touch the clean and before each weighing a clean measuring board and the eye and external auditory meatus cloth or paper should be spread on it. should be in a horizontal line

Fig. 7 : Infantometer. Note the fixed head piece and the sliding foot board. The measuring scale is fixed along the side of the bard on which baby is lying

19 along the length of the board. It has a ends should not be worn out. At any rate, vertical fixed head piece on one end (see the end is not used when measuring to fig). A moveable, L-shaped piece is used to avoid error. slide along the board to touch the sole of the The technique: Measurement involves baby's foot for measuring. The length can be the principle of "cross tape" technique. The read directly from the tape. A sophisticated tape is crossed around the head or limb to be but expensive equipment is also available measured (Fig. 8 & 9) and the reading is called the stadiometer which has a ball made where the figures cross, avoiding use of bearing, sliding rod which gives the reading tape ends. While measuring the head the directly in the window of the meter (like tape should be horizontal and take the milometer in a car) maximum circumference around the occipital The technique: For measuring height, protuberance and other eminences. While the child stands on the platform without measuring a limb to compare with the shoes. He is made to stand erect against the opposite, the level at which measurement is board with the heels, buttocks and the taken should be similar and to ensure this, occiput touching the board. The chin should the level of measurement should be a fixed be straight and the eyes and the external distance from a prominent bony point above auditory meatus should be in one horizontal the limb. For example mid arm circumference line. The head piece is then lowered along should always be taken from a fixed distance the board to touch the vertex and the below the shoulder trochanter on either side. reading taken against the tape. Height can 4. Skin fold measurement: be measured against a wall provided care is taken of the position of the child as The instrument: Skin fold calipers are explained, to ensure accuracy. used for the purpose. A skin fold is measured from the biceps, triceps or the sub 3. Circumferences: scapular region as required. It includes the The instrument: Those frequently skin and two layers of fat which can directly needed to be measured are circumference of be measured in the dial. the head, arm, chest or limbs. A good non- The technique: A fold is picked up stretchable fiberglass tape is required. Its softly from the area chosen and the prongs

Fig. 9 : Measuring arm circumference by the cross tape technique. The site of measuring is the point equidistant between acromain process of the shoulder Fig. 8 : Measuring head circumference. and the olecranon of the Note use of the 'cross tape' technique to ulna. This is to enable avoid use of the worn end of the tape uniform comparison

20 of the calipers released to allow the spring 15 months: First Molars to touch the folds picked up. The reading is 18 to 24 months: Canines directly taken from the dial. 2 to 21/2 years: Second and last Skin fold measurement is not used temporary molars (Thus routinely in practice. by about 21/2 years, primary dentition is 5. Testicular size complete. Total teeth 20) The instrument: A series of numbered At 6 years: First permanent molars plastic balls (measured in cc's) from size 1 cc appear to 25 cc, threaded together are available Permanent dentition: under the name of 'test size'. (See Fig. 10) 7-8 years: Central incisors 8-9 years; Lateral incisors 11-12 years: Canine 10-11 years First premolar 10-12 years Second premolar 6-7 years First molar 12-13 years Second molar Skeletal Age by Radiology Fig. 10 : 'Test-size' for measuring testicular size in cc's This is assessed by taking X-ray by comparison with a series of standard sized beads pictures of bones at specific sites. Most commonly X-ray of the left wrist, hip and The technique: One of the testes is knee are taken. Ossification centers appear palpated with one hand for size and the at specific ages and enable determination of beaded balls in the other hand are felt to bone age. Detailed charts are available. choose the one that measures the same as Abnormalities such as delays of maturation the testes. or advanced bone age occur in certain Clinical and radiological growth metabolic or endocrine disorders and help assessment in diagnosis of such disorders. Some commonly used parameters are as under: Clinically, examination of teeth, l ossification of bones by radiology for At birth: Centers present at birth are: assessing skeletal age, appearance of Distal end of femur, proximal tibia, femoral head, calcaneus, talus and paranasal sinuses by X rays, palpation of cuboid fontanels etc is carried out to see if growth l is appropriate and as expected for age. End of first year: Upper end of These are briefly discussed below. humerus, two carpal centers. l After first year one carpal center Teeth (dentition): appears for each year so that by the Primary dentition: (starts at about 6 months) end of 6 years 7 centers are present l 6 months: Eruption of Central From 8 to 12 years: Distal epiphysis of incisors ulna appears ( girls by 8 to 9 years, 8-12 months: Lateral incisors (By about boys 10 to 12 years) 1 year 4 to 8 l 12 to 16 years: Distal ulnar end, lesser teeth appear) trochanter and iliac crest. 21 Paransal Sinuses Para nasal sinuses are cavities lined Occipital bone with mucous membrane, within bones near the nose, four on either side and include the Posterior Fontanel frontal, the maxillary, the ethmoid and the Sutures sphenoid. The maxillary sinuses: largest, on Anterior Fontanel either side of the nasal cavity within the maxilla. It is present at birth The frontal sinuses: present behind the frontal bone The ethmoid sinuses: behind and Parietal bone below the frontal sinus. It is present at birth The sphenoid sinuses: Behind the ethmoid sinus deep in the skull. Most sinuses are rudimentary at birth and get pneumatized, (filled with air) with Frontal bone age when they can be visualized with the help of x-rays. Maxillary sinuses can normally be trans illuminated with a torch Fig. 11 : Showing the fontanels and cranial sutures between skull bones light in the closed mouth. If opaque, it suggests inflammation. 18 months and the posterior by about 2 months. If there is increased pressure Fontanels and Skull Sutures inside the cranium, the fontanels may bulge The skull bones, (Fig. 11) including as in meningitis, hydrocephalus, subdural the frontal, parietal, temporal and occipital, hematoma etc. Increased fluid inside the are separated by sutures which are not skull can be made out sometimes by united at birth. These allow the brain to transillumination: - in a dark room a brightly grow rapidly inside the skull in the early lit torch is placed over the skull and years of life. When bone growth is complete, illumination can be seen indicating fluid the sutures unite. If however, one or more inside, as in a large cyst or hydrocephalus. sutures are fused at birth (called synostosis), the skull cannot grow leaving the brain small Growth at adolescence and the child retarded. If diagnosed Physical Growth promptly and the sutures are surgically opened early, it can save a child from This comprises increase in weight, becoming handicapped. Normally open height, other parameters and body sutures at birth, leave spaces between them proportions. There are differences between called fontanels. The prominent ones that boys and girls. Girls begin their pubertal can be felt with the fingers are: the anterior growth spurt earlier (around 10 years) than fontanel between the two parietal bones and boys (around 14 years) and also finish their the frontal bone. The posterior fontanel is growth earlier. Boys begin their spurt a between the occipital and parietal bones. couple of years after girls and take longer to The anterior normally closes by about 12 to end up later and ultimately taller than girls 22 (Fig. 12). As growth proceeds, legs, arms, child falls and following that percentile hands and feet grow faster than the trunk in curve to the end and reading the both boys and girls. Girls get wider at the predicted ultimate height at 20 years. hips and boys at their shoulders. Boys are (See growth charts Appendix I): more muscular and have heavier bones, with Example: Suppose a boy is 2 years sharp angles. Girls on the other hand, have old and his height is 86 cms. If you more body fat and therefore, have rounder look at the height chart for boys from 2 contours. These differences are the result of to 18 years, you will see that he falls in male and female hormones. The stature the 50th percentile (fourth line from the (height) of a child can be predicted with bottom). Following this line to the end reasonable accuracy in two following ways: (20th year) reads 176 cms. This will be 1. From "Mid parent height" (MPH): the boy's likely ultimate adult height. Add mother's and father's height in Sexual Growth cms. And divide by 2. This is called the MPH. For predicting the son's During puberty certain changes occur ultimate height, add 13 cms and for in boys and girls before they end up predicting the daughter's, subtract 13 ultimately as mature adults. cms from this MPH. a) Both boys and girls grow hair in the Example: Suppose father's height is armpits and around the genitals. 180 cms. and mother's 160 cms. The b) In boys puberty begins with the MPH will be 180+160=340 divided by enlargement of the scrotum and testes, 2, i.e, 170 cms. The predicted height followed by the growth of the penis for a son will be 170+13= 183 cms. until adult stage is reached. Voice and for a daughter 170-13= 157 cms. deepens and facial hair grows in the 2. From the growth curve: form of the moustache and beard. Puberty is complete with occurrence of A more precise prediction can be made nocturnal emissions. from noting the percentile in which the c) In girls puberty begins with enlargement of the breasts. First the breast bud appears and the areolar diameter increases. (Areola is the dark circle around the nipple). Then the areola elevates to form a mound which finally recedes into the general breast contour. Puberty in girls ends up with onset of menstruation. (First appearance is called 'menarche') This occurs usually around 12 to 13 years but could range from 11 to 15 years. Secondary sexual growth has been 20 described in 5 stages, each for boys and girls, by Tanner and his colleagues and is Fig. 12 : Velocity growth curves of known as Sexual Maturity Rating (SMR) boys and girls from infancy to adolescence (Fig. 13). 23 Sexual Maturity Rating (SMR) stages in Boys (Tanner)

Stage Pubic Hair Penis Scrotum/testes 1. None Preadolescent Preadolescent 2. Scanty, Long, Slightly pigmented Slightly enlarged Scrotum slightly enlarged, pink, texture altered Testes size>4ml 3. Darker, start to curl, small amount Longer Testes size>8 ml 4. Adult type but less in quantity, Longer, glans and Larger, scrotum dark, Testes course and curly breadth increase in size size > 15 ml 5. Adult in distribution, spread Adult size Testes size adult: 18-25 ml. to medial side of thigh Sexual Maturity Rating (SMR) stages in Girls (Tanner)

Stage Pubic hair Breasts 1 Preadolescent Preadolescent 2 Sparse, lightly pigmented, straight, Breast and papilla elevated as a small present on medial border of labia mound, areolar diameter increased 3 Darker, beginning to curl, increased Breasts and areola enlarged, no contour in amount separation 4 Course, curly, abundant but amount Areola and papilla form a secondary mound less than in adult 5 Adult, feminine triangle, spread to medial Mature nipple projects, areola part of general surface of thigh breast contour YS B. BO

I II III IV V

Breast A. GIRLS

Ext. Genitals

I II III IV V Fig. 13 : Tanner's Sexual Maturity Rating (SMR) : (A) girls and (B) boys. Note appearance of breasts and genitalia in girls and genitalia in boys from before the beginning of puberty (Stage I) to completion of maturity (Stage V) 24 Psychological Development intense peer-relationship, the It begins with a child's emotional adolescent has learnt social skills, reaction to his/her pubertal changes and which are utilized in mastering the ultimately extends finally to a reasonable environment and preparing for a resolution of personal identity. During this future career. At this stage the critical period the adolescent needs to adolescent may be called upon, for the master certain developmental situations to first time, to shoulder responsibilities assume an adult role and these include: involving occupational commitments, Independence from parents; adult sexual interpersonal relationships and even drives; establishment of an identity and pregnancy, child birth and parenthood. delineation of educational and occupational An adequately prepared person meets goals. These can be understood in the these responsibilities, improvises following three phases: strategies to cope with problems and (a) Early adolescence-the period of emerges successfully through the puberty critical transition from adolescence to adulthood. Poverty, social deprivation, Seeking independence from parents sickness, lack of opportunities and yet relying on them for physical and psychosocial stimulation, particularly emotional support. The conflict in early life, can seriously affect social sometimes results in contradictory adaptation and development of mature behavior. Parents are often blamed for adult personality. difficulties they encounter. Rapid physical and sexual changes confuse Behavioral growth: the adolescent making him/her unsure A child learns basic skills, like sitting, of ability to control these strange standing, walking, and talking rapidly during feelings. There is preoccupation with the first 5 years. Complex activities of oneself which interferes with coordination of movement, changes in interaction with others, including emotional behavior and intellectual skills parents. Participation in sports develop increasingly with age. They follow a provides a socially acceptable avenue sequence and are achieved at given times for release of tensions. with a range on either side of an average. These averages and age ranges at which a (b) Mid-adolescence-the period of child is normally expected to perform is identification called his developmental age. Comparing Now less occupied with oneself, is this with his actual (chronological) age intensely involved with peers, drawing provides a mathematical index of what is emotional security from them. He/she termed a Developmental Quotient or DQ is now more independent of parents and is calculated as under: who serve as important role-models. Developmental Developmental Age x 100 As age advances, they become more = occupied with academic achievements Quotient (DQ) Chronological Age and vocational issues. Example: Suppose a child is 25months old and when tested performs (c) Late adolescence-the period of what a normal child is expected to perform coping at 24 months. Having passed through a period of His DQ will be 24 / 25 x 100= 96 25 Which means he is within his normal children. performance range? Screening tests: A large number of If however, the Developmental age is tests are available internationally such as the much lower than his actual age, he is in the Denver Screening test, Nancy Bailey's scale lower DQ range and may need to be and many more. For Indian children the followed up for he may need help in Baroda (Pathak's) screening test and developing his future performance. As Trivandrum Development Screening chart stated already, 'normal' is never a fixed have been devised, in view of cultural point but has a range of normality below differences between countries and regions, and above the 'average' like weight or World Health Organization (WHO) height. Those below the lower range of conducted a multi center study in China, normal are considered developmentally India and Thailand on a very large number retarded and need special care in training of children, the largest study of its kind ever and education. Those well above their undertaken. (Bulletin of the World Health performance age (developmental age) are Organization 1996, 74(3)283-90) The superior or gifted children. Indian centers that collaborated in the study Performance of children below 5 years were Chandigarh, Hyderabad and Jabalpur. is assessed in four major areas: Based on the study, 13 culturally = Motor: Includes activities like appropriate test items (milestones of sitting, standing, walking etc development) were selected for use in home based growth monitoring records. These are = Adaptive: Those activities that involve eye-hand coordination, rapid screening tests for preliminary testing such as building a tower of or for the use of primary health workers and cubes, threading beads etc. if they indicate delay in development, more elaborate tests are carried out by experts = Language: Hearing and speech before any interventions are carried out. activities Certain prescreening charts are = Personal social: Like toilet available which can be filled by literate training and other social skills. parents while awaiting their turn in a clinic. There are tables and charts available One such is the RPDQ developed by the for children below the age of 5 years Denver group of workers for children in four showing the normal and range of normality age groups: 0 to 9 months, 9 months to 24 above and below an average for experts months, 2 to 4 years and 4 to 6 years. who are trained to assess children. But for (Appendix II) quick and routine day to day work screening charts are available. One such chart appears Growth monitoring in children at p. 27. under five years For children above 6 years who can The 'Under Fives Clinics' verbalize freely, standard Intelligence The "Under Fives Card' Quotient or IQ tests and techniques are The highest rates of sickness and available. IQ's can be derived like DQ's. death among children occur in those below Tests have been developed specially for the age of five years. This age period is Indian children in view of cultural and social critical because of the transition in diet, differences from tests devised for western immunity, vulnerability to harmful 26 Milestone of Development

Age Motor Adaptive Language Personal Social Activity Behaviour Behaviour 3 Supports head. Raises Follow light in Bah-ing and Smiles on fondling. months head to 75°-80° in all directions. goo-ing sounds. Recognises mother. supine position. Posture Sleep pattern symmetrical tone normal. established with waking Specific neurological periods. reflexes disappear. 4-5 Turns over from prone to Reaches out for Listens and - months supine or supine to prone. objects and begins responds to visual accommodation. talking. 6-8 Site up, first with support Holds objects, puts Makes different Recognises new people months and then independently. them in his month. sounds. as strange. Holds toy or Localises aural stimil. Transfers an object from rattle. Toilet training one to another hand. can be started. 9-10 Stands with support. Holds two objects. Vocalises Likes to play hide and months Crawls. Pincer grasp. sounds. seek. Withdraws from strangers. Can eat by himself. Drinks from a cup. 11-12 Bear crawl, then stands Releases objects. Speaks in single Eats and drinks by himself. months alone. Walks with support syllables Can indicate the urge to and then alone. pass faeces. Gradually acquires bowel control. 13-15 Walks alone. Climbs up Scribbles in circles. Beginning to Obeys orders. months the furniture/staircase. Balances one cube on join words. another. 16-20 Runs, climbs up and Matches objects. Speaks in Identifies different months down staircase. Scribbles in lines. Puts sentences. parts of the body. Imitates block in a hole. Identified people around. common objects. 21-24 Jumps Matches shapes. Names familiar Helps to dress himself. months Scribbles. objects. Fond of listening to stories. Complete bowel control and dry during the day. 3 years Stands on one leg. Writes, draws, can Reads, recites Identifies family members. Can walk backwards. imitate a triangle. nursery rhymes. Calls them by name. Eats. Rides a tricycle. Kicks a ball. Can tell name. Dreams. Dry by nights. 4 years Runs. Jumps. Hops. Can copy a square. Speaks well. Can play in group with Draws. Nouns, pronouns, other children. Can put his adjectives, verbs. chappals on right way. 5 years Acquires further stability Can identify coins. Remembers Knows strangers by name. Compares long and short. incidents, past Understands good from bad. memory. 6 years Can hop Can do simple arithmetic. Reads, writes, Plays in group. Dreams. Recites poem. Undresses, puts on shoes and ties shoe laces. environmental hazards and increased one of the main reasons for poor acceptance proneness to accidents and infection. The of family planning by parents. Health care high rates of death instill a sense of of children in this age group is therefore, a insecurity among parents regarding their national priority. To fulfill this commitment, survival, resulting in high birth rates. This is health care of children under five in the

27 community is carried out through 'under which is retained by the mother for visits to fives clinics' through a number of activities the center and for home visits by the health aimed at anticipatory surveillance and worker. This is required to be brought to the timely intervention: clinic at every visit for weighing, l Growth and development monitoring development assessment, and immunization l and to receive any instructions and Identifying children at risk for treatment if necessary. This card is popularly malnutrition and developmental referred as the 'road to health card', first retardation designed by David Morley and later l Early intervention for malnutrition modified by the WHO for international use. l Early intervention for developmental The components of this card are: retardation l Weight curves for upper and lower l Education of mother in respect of limits of 'normal' growth. For purposes nutrition, immunization, oral hydration of this card the upper curve is the 50th and family planning percentile for boys and the lower curve, 5th percentile for girls. Between l Referral to higher centers as required. these two lines is the 'road to health' Central to this concept of under fives and any child whose weight plotted on care is an 'under fives card' (see below) this chart from time to time deviates AN UNDER-FIVES CARD (ROAD TO HEALTH CARD)

28 from this 'road' is considered a given age and serve as talking point to candidate for malnutrition and educate the mother. managed accordingly before the child l Family planning advice is provided at succumbs to malnutrition. appropriate visits when the mother is l Developmental milestones at key ages receptive, emphasizing the advantages shown with sketches in the card of a small family norm. indicate achievement expected of a l Educational tool. The card is a good child at the given age. Any delay at educational tool providing arriving at the expected milestone is opportunities for health interventions an indication for further assessment such as oral hydration, child rearing and appropriate intervention through practices, weaning foods, cooking a program of psychosocial stimulation. methods, personal hygiene and similar l Immunization record indicates the mother craft activities vaccinations given and further shots Effective use of these cards has shown due. substantial reduction in death and sickness l Nutrition education is provided with rates. Such cards can be used effectively at the help of symbols on the card that 'Anganwadis' under the ICDS programme indicate foods that can be given at a (See p. 43-44). 29 Normal Nutrition and 4 Nutritional Requirements

Food provides energy for growth and maintenance of the body. Children have different requirements at different ages. Breast feeding takes care of growth during early infancy. As requirements increase, supplementary foods are added to breast 1st plank feeding. After breast feeding is over, a child depends entirely on food provided by his 2nd plank 3rd plank care takers, namely parents and others if it is a joint family. So long as an infant is breast fed, his requirements are almost entirely met by the breast milk approximately for the first four to six or more months so that growth during this period is likely to be adequate irrespective of the parents's education, economic status or culture. After this age however, introduction of other foods depends upon family education, income, cultural practices, superstitions and religious beliefs. These external factors determine how well the child is likely to grow after Fig. 14 : Jelliffe's "3 plank bridge" infancy. In poor, undereducated families for preventing malnutrition malnutrition and sickness are common. A 2nd plank: Supplementary feeds introduced common scene among poor, early (not later than 6 months). underprivileged communities is a plump 3rd plank: Immunization against breast fed infant in the mother's lap and an preventable childhood infections underweight older sibling trudging along that inhibit growth. with the mother. This situation adequately emphasizes the need for mother's education Terms used in the field of nutrition in terms of nature and quantity of food Nutrients: An adequate diet to required by growing infants and children. ensure normal health should provide Proteins, Carbohydrates, Fats, Vitamins, The concept of a "three plank bridge" minerals and trace elements. The first three Jelliffe (see Fig. 14) is used to carry the of these nutrients provide energy measured message for healthy growth from age 6 in Calories. months to 2-3 years: Calorie or Kcal: This is the unit of 1st plank: Continued breast feeding energy provided by proteins, carbohydrates beyond one year and fats. Each provides calories as under: Protein 4 Calories/gm nutrients that ensures adequate growth health and vitality and additionally provides Fat 9 Calories/ gm for cover against minor illnesses of short Carbohydrates 4 Calories/ gm duration. The proportion of calories in a balanced daily diet that should ideally be Sometimes the term Joules is used in provided by protein, fat and carbohydrate is place of Calories as under: Recommended Daily Allowance Protein: Should at least provide 10 to (RDA): Many terms are used to express the 15% of calories amount of nutrients needed by the body such as minimum daily requirement, Fat: Should provide 15 to 30% of calories optimum daily requirement etc., but the most commonly used is RDA and is based Carbohydrate: Should provide the on minimum requirements plus extra needs remaining about 60 to 70% of growth, stress etc., that is sufficient for Nutritional requirements maintenance of good health The daily requirement of Protein and Reference Protein: This expresses calories in different age groups is as under the quality of protein compared to egg (National Institute of Nutrition, India 1972). protein as a reference. A rough estimate for calories is: Net Protein Utilization (NPU): First year: 1000 calories Utilization of protein by the body depends on its digestibility and its quality. Thus NPU (Add 100 calories per year is defined as: for 2, 3, 4 and 5 years): Digestibility Coefficient ÷ Biological Second year: 1100 calories/ day Value × 100 Third year : 1200 calories/ day More precisely: Nitrogen retention in Fourth year: 1300 calories/ day the body ÷ Nitrogen intake × 100 Fifth year: 1400 calories/ day (In terms of quality of protein, 1 gm protein is equivalent to 6.25 gms Nitrogen) AGE WT. CALORIES PROTEINS Amino acid score: Amino acids (kg) (kcal) (g) make up essential component of protein. 0 to 6 mth 5.4 92 kcal/kg/d 1.168/kg/d Amino acid score is the concentration of each essential amino acid as a percent of 6 m -1 yr. 8.4 80 kcal/kg/d 1.168/kg/d that amino acid in the reference protein (egg 1-3 yrs 12.9 1060 16.7 protein). Precisely: 4-6 yrs 18.0 1350 20.1 Mg. of a given amino acid / gm protein ÷ Mg of that amino acid per gm egg protein 7-9 yrs 25.1 1690 29.5 × 100 10-12 yrs 34.3 2190 39.9 Balanced Diet: combination of

31 Breast feeding infection. These include Ancient Indian texts and tradition have immunoglobulins, lysozymes, greatly eulogized the role of breast feeding complements, lactoferrin, T and B of infants: lymphocytes, bifidus factor, antiviral factor, antistreptococcal factor and Benefits to the baby: PABA (para amino benzoic acid) l l Readily available to the baby Minimises the risk of allergic disorders, l Clean and sanitary. dental caries, sudden infant death syndrome. l Emotional satisfaction to the baby and better infant-mother bonding Benefits to the mother: l Most appropriate for the baby's needs l Convenient in terms of nutritional requirements. Its l Cost free. Saves the family cost of top protein is most suitable for the infant. milk It has a rich content of fatty acids. l Provides the richest source of lactose Helps in the involution of the uterus as compared to other milks and after delivery l contains the enzyme lipase which aids Mother-infant bonding and emotional in proper fat digestion. satisfaction to mother l l It has several anti-infective agents Reduces breast and uterine cancer risk. which protect the baby against serious l Child spacing.

32 Composition of breast milk compared Colostrum: to other milk The yellow, thick milk secreted during Breast milk is a natural food meant for the first 3 days is called Colostrum.It is rich the human baby while animal milk is meant in antibodies, leucocytes and protein and for the calf of that animal. The quality and provides many nutritional and immune quantity of various ingredients of human factors that protect the child during early milk precisely fulfill the requirements of the infancy. It is often discarded because it looks human baby and provide immune and thick and greasy, but the baby must never nutritional factors which animal milk cannot be deprived of this. provide. Formula milks available commercially attempt to modify the formula The anatomy and physiology of to suit the baby but cannot match breast milk lactation. (Fig. 15 & 16) in quality, particularly because they do not The breasts consist of alveoli, fat and provide the anti-infective factors. Besides, if other tissue to support the alveoli which formula milk is not prepared properly, excess form milk. Milk ducts carry milk from these of powder in the mixture or if too diluted can to the nipple. Before ending at the nipple cause complications. These include obesity, these milk ducts form milk sinuses where malnutrition, electrolyte disturbances like milk collects. excess sodium or hypocalcaemia (in view of A hormone 'prolactin' is formed by the inability of the kidney to handle the solute anterior pituitary on stimulation of nerve load of formula milk). endings by the suckling baby. This hormone Composition/ Human Cow's stimulates the cells in the breast glands to 100 ml milk milk secrete milk ('Prolactin reflex'). Another hormone, 'oxytocin' secreted by the Protein Casein 1.1 gm 3.5 gm posterior pituitary, contracts the muscle cells 30-40% 80% surrounding the alveoli, squeezing the milk Lactose 6.5 gm 4.5 gm from the nipples ('Let-down reflex'). Any Fat 3.5 3.5 emotional disturbance of the mother can Calories 67 Less but added sugar increases adversely affect the oxytocin secretion calories resulting in failure of successful breast Calcium/ More than Less than feeding. Continued breast feeding in a Phosphorus 2 2 happy and relaxed situation ensures larger ratio (Predisposes to tetany) quantities of milk- more the breast feeding Ash content 0.2 gm 0.7 gm more the secretion. (Na high, Fl low) Nutients The art and science of breast feeding. Iron Higher Low Young mothers in joint families and Folic acid Higher Low those in rural areas observe other mothers Vitamin B12 Lower High feed their babies so that by the time they Vitamin C Higher Low become mothers they have no difficulty in Vitamin A Lower High breast feeding their own baby. Mothers in Vitamin D Higher Low such societies have no taboos in nursing Vitamin K Lower High babies even in public places since they feel ANTI INFECTIVE Much more Poor breast feeding is a normal and natural AGENTS rich process. However, in upper class nuclear

33 Milk Duct

Alveoli

Fig. 15 : Physiology of lactation involving anterior pituitary Fig. 16 : Anatomy of lactation (prolactin) and posterior pituitary (oxytocin) hormones (showing section of breast) families where mothers breast feed their children in absolute privacy, the mothers-to- be do not have this opportunity of learning so that in their own turn they need help in order to be able to breast feed successfully. Breast For this reason breast feeding is natural and successful in poor, rural and in joint families. Areola Antenatal care of breasts: In order Nipple for breast feeding to be successful, the breasts need to be prepared before the baby is born, during antenatal visits. The mother should wash her breasts twice daily, each time rubbing a little oil or lanolin into the alveolus and gently molding out the nipple and areolus from the underlying tissues so Tongue Gum that the tips of her fingers come together at the base of the nipple. From 30th week of pregnancy, gentle massage along the ducts towards the nipple encourages the flow of colostrum which escapes from about the Fig. 17 : An infant showing section of the sucking mechanism. Note the nipple is well inside the mouth 34th week. while the baby draws milk from the areola. The process of suckling: (See Fig. This indicates how flat nipples result in lactation failure because the nipple cannot 17) It is important to understand this process be drawn well inside the mouth

34 in order to help the mother. The baby sucks glucose honey 'ghutti' etc) should be not at the nipple but around the areola under given after delivery and before the first which lie the milk sinuses. In fact, during feed. suckling, the nipple is well behind at the back l Immediately after a feed the baby of the mouth between the tongue and the should be 'burped' in an upright hard palate. The baby's gums and tongue position held across the shoulder by squeeze the milk from the sinuses under the the mother and gently patted on the areola which squirts through the nipples. If back. The baby should not be put flat the nipples are retracted, the baby cannot on the bed immediately, nor fed in draw the nipple well into the mouth and lying position. when hungry, he sucks at the nipples. Because he cannot get milk like this, he bites The indicators of successful at the nipples causing cracks and fissures breast feeding are: resulting in breast infection and abscess. l Satisfied mother and baby The technique of breast feeding: l Satisfactory weight gain of about 30 Experienced mothers may not have gms per day difficulty feeding their babies but a young l Normal golden brown, pasty stool, mother with her first baby needs help and normal urinary output. support. l Test feeding: The baby is weighed on l Baby needs to be put to the breast not an accurate and sensitive scale before later than 2 hours after delivery. and after a feed, the difference l Feed ever 2-4 hours based on indicating the amount ingested by the demand. baby. Such weighing is carried out at l Mother should sit up during breast each feed over a 24 hour- period to feeding estimate the total intake during the l The mother's arm should support the day. On an average this should be baby's shoulder with the baby's head about 100 ml per kg per day. This is raised. the total fluid intake required per day at this age which, in the case of an l Mother touches her breast to baby's exclusively breast fed baby, is the cheek so that the baby turns his mouth breast milk. Thus a baby weighing 3 searching for the nipple (rooting reflex) kg, for instance, should take 100 x 3 = and draws it into his mouth. 300 ml milk per day. This test is not l The mother needs to make it an conventionally carried out now. enjoyable experience for herself and the baby, looking at her baby while When not to breastfeed: Breast feeding feeding. It should not be casual or a is contraindicated only in certain special, ritual process but deliberate interaction though unfortunate situations for the baby. between the two. These are: l l If the baby is satisfied after emptying Mother on anti cancer drugs; one breast the other can be offered at l Tuberculous mother; the baby should the next feed. If not he could be fed have Isoniazid for 3 months (10 mg/kg from both breasts at each feed. body weight) single morning dose, l No other feeds (prelacteal feeds like followed by BCG vaccination 35 l Critically or severely ill mother or in Baby Friendly Hospital Initiative debilitating conditions & HIV. (BFHI) l In breast abscess breast feeding should In March 1992, WHO and UNICEF only be stopped temporarily launched an initiative aimed at preserving breast feeding practice and to prevent large Some problems in breast feeding: scale deaths from malnutrition and l Breast engorgement: This occurs on infections associated with bottle feeding. A the 3rd to 5th day after birth of baby, code of conduct already exists for baby food usually in the first pregnancy if the manufacturers and others, any breach of breasts have not been prepared which attracts penalty. These relate to manufacture, advertising and in any manner antenatally (See antenatal care of promoting formula and bottle feeding The breasts above). This results from lack baby friendly initiative aims at educating / of opening of milk ducts and sinuses training health workers so that they are for want of massage during the equipped with information and skills in antenatal period. Because milk cannot encouraging breast feeding practices. The escape, breasts become engorged, following criteria are essential for a hospital hard, heavy and tender. As the areolus to claim to be Baby Friendly: is stretched from underlying pressure, l A written breast feeding policy for the the baby is unable to draw the nipple health staff into its mouth. The management is: l Training skills for health workers in the physical support, a mild analgesic, implementation of this policy cold compress and gentle expression l of milk. If fever occurs an antibiotic is Providing information to pregnant required. In about 24 to 48 hours the mothers relating to benefits of breast engorgement is usually relieved. feeding and its management l To encourage and help mothers in l Cracked nipples: If the baby cannot initiating breast feeding within half draw milk from the engorged breast, hour of birth he bites at the nipple in frustration l from hunger. This causes cracks and Demonstrating to mothers the fissures which are painful and further technique and maintenance of breast feeding diminish flow of milk. The treatment is rest (baby is kept off the breast), the l Discouraging mothers in the use of milk expressed manually and fed to the feeding food or drink other than breast baby until, in course of time the cracks milk. heal l Encouraging rooming in and infant mother contact l Breast abscess: Engorgement and l painful nipples result in abscesses in Encouraging feeding baby on demand the 2nd or 3rd week after delivery. rather than on any time schedule Symptoms are fever, rigor, and tender l Avoidance of pacifiers. hard areas in the breast. Treatment: l Encouraging formation of breast Antibiotics, physical support of breast feeding support groups and and if delay has occurred, incision and participation of mothers in such surgical drainage. groups. 36 Preventive and 5 Community Pediatrics

Health l Domestic environment that includes When we talk of health, we do not Physical (housing), Social (household) mean just the freedom from disease. As and the Resources (job, earning defined by the WHO, "health is a state of resources). complete physical, mental and social The Macro environment includes wellbeing and not merely an absence of climate, terrain, water, population and disease or infirmity". To this definition a interactions with other families. recent addition has been made to include A child growing in a family is therefore the ability to lead a socially and influenced by all these factors and does not economically reproductive life. To achieve grow in isolation. The child is a reflection of these apparently broad goals, health the sum of the total forces acting on and personnel are not the only people who are within the child's family. Thus the thinking responsible. The whole nation at every level of the nurse and her actions must not is involved- public health, education, separate from this background when engineering, water supply, rural providing care. She is forced to think in development, agriculture, road building, terms of all complexities of family life in transport etc. understanding and caring for children Family health and Child Health: The family life cycle: Great variations exist in each culture When two people marry and live and depend on religious, regional, cultural together they form their own family which and other differences among families. The follows the following phases: concept of family health must therefore be related to rearing of children and factors 1. Formation: Begins at marriage and ultimately influencing the growth and ends at birth of the first child development of children. 2. Extension: Begins at birth of the first A child is born into a family. A family child and ends at birth of last child is a group of people living together which is 3. Completed extension: Begins at birth subject to the environment- a Micro and a of last child and ends when the first Macro environment. child leaves home The Micro environment includes the 4. Contraction: Begins when first child structure of the family (father, mother, sibs leaves home and ends when the last etc) and the dynamic relationships within it. child leaves home. l The family variables are number, ages, 5. Completed contraction: Begins when genetic inheritance, health, last child leaves home and ends when personality, education and occupation first spouse dies. of the members constituting the family. l 6. Dissolution: When first spouse dies Family functions include biological, and ends when the surviving spouse economic, social, educational and dies. psychological. The length of this cycle depends upon taken before the onset of disease so that age at marriage and length of life, but there is no chance of a disease to appear. subject to stress and crises such as illness, There are two aspects to this: Specific accident, poverty or family breakdown by protection and health promotion. The object death, divorce, desertion etc. Family health is to institute specific action against specific and health of the child in the family are diseases, improve life styles, educate people inseparable and should therefore be seen in about risk factors and bring about attitudinal the light of all factors discussed above. change with regard to positive health. Requirements for family health: Secondary prevention: Once the disease has set in, secondary prevention These requirements are: aims at halting further progress of the 1. A healthy genetic inheritance disease and to prevent its complications. 2. Birth spacing and care. This is possible through early diagnosis of the disease condition and its prompt 3. Adequate food for the family treatment. 4. Protection from noxious influences Tertiary prevention: comes at a further such as infection and injury stage where a disease has already set in but 5. Recreation where further complications need to be 6. Care of the aged. stopped. This involves disability limitation and rehabilitation of the afflicted person in Levels of prevention in health care life. It is often said that: Let us illustrate this with the help of "Prevention is better than cure" examples: Prevention of poliomyelitis for "An ounce of prevention is worth a instance is done through all these three pound of cure" stages. Primary prevention is possible through specific protection, which means Preventive health care is better giving polio vaccine to every child. Health because it is cheaper and therefore wiser. promotion for polio will include preventing There are three levels of prevention in oral fecal contamination from polio virus by health care: cleanliness and hygienic measures. 1. Primary prevention: Secondary prevention is possible by a) Specific protection diagnosing cases early and to treat promptly b) Health promotion to avoid complications as far as possible. Once paralysis is established, tertiary 2. Secondary prevention: prevention will include disability limitation a) Early diagnosis with the help of orthopedic appliances and b) Prompt treatment physiotherapy and rehabilitation by training for livelihood through vocational training 3. Tertiary prevention and help. a) Disability limitation Let us take cancer as another example. b) Rehabilitation. Primary prevention means educating masses These need to be explained: about health styles, against consumption of tobacco and similar harmful agents such as Primary prevention: means action chewing tobacco, gutka etc which will

38 reduce the incidence of cancer. As FEATURES ACTIVE PASSIVE secondary prevention, if cases are diagnosed early, surgical intervention, Duration of Long lasting Temporary. medication and irradiation could prevent protection (days/weeks) deaths and prolong lives. Tertiary Protective Better, up to Wanes and prevention would mean helping patients to efficacy 100% thus less live as fruitful a life as possible by limiting Time to develop Takes time Immediate disabilities arising postoperatively or after immunity irradiation and rehabilitating them within Cost Vaccines less Anti-sera the constraints of any residual infirmities. expensive expensive Severe reactions Infrequent Can be severe Immunization of children with sera. Some basic facts about immunity Active immunity is of two types: Humoral or cellular. It is beyond the scope of this book to go into details of immunity which can be 1. Humoral immunity develops from found in books specifically dealing with the lymphocytes derived from the bone subject. Here a brief account relevant to marrow called B-lymphocytes. After an immunization of children is given. antigen is presented to these cells, they proliferate and form antibodies which Immunity can be a) Active or locate themselves in the serum b) Passive. immunoglobulin (IgG, IgM, IgA, IgD (a) Active immunity develops after and IgE). The antibodies produced are contacting a disease, e.g. if a child gets specific to one antigen which means chicken pox, he becomes immune to it that they do not protect from another by producing its own antibodies antigen so that one vaccine is not against chicken pox. He may not get effective against all types. chicken pox again. Active immunity 2. Cellular immunity develops from also develops after immunization with lymphocytes derived from the thymus a vaccine or toxoid. It is called active called T lymphocytes. Lymphokines, because the body forms its own secreted by suitably stimulated T- antibodies against the disease. lymphocytes, stimulate macrophages (b) Passive immunity on the other hand, (mononuclear leucocytes) to produce occurs after ready made antibodies are much stronger phagocytic activity than introduced to a child. Such antibodies the unstimulated mononuclear are produced in an animal, for leucocytes. T-cells are responsible for example horse by injecting antigens recognizing an antigen and react to it into the horse. The horse's serum then by setting up a series of actions produces antibodies against this including stimulating macrophages, antigen. This serum, or the antibodies releasing cytotoxic factors, secretion of in it, can be injected to a patient in interferon etc. Thus cellular immunity need of it. It is called passive because has an important role in resistance to the patient's own body does not infection particularly tuberculosis, produce it but gets it ready made. The leprosy, brucellosis typhoid and differences between the two forms of several viruses. A defect in cellular immunity are as under: immunity is much more serious than

39 humoral. The deficiency in the former from these organisms (e.g. E.coli). Breast may result in death in months while in milk and colostrums provide good the latter survival may be possible for concentrations of immunoglobulins some years. particularly in the gut that protect against During fetal life: The fetus has infections acquired from the oral route. almost no immunity for the first three Malnutrition, overwhelming infection, months. From then on, the lymphoid system prematurity and preterm delivery, burns, of the fetus gets increasing number of cells major surgery and emotional stress can all that are capable of developing immunity suppress immunity in one way or another. and in the next six months plasma cells are Congenital absence of thymus gland and formed that can produce immunoglobulins poor follicular formation in lymph nodes of IgM and IgA type but their concentration and spleen can cause is low. Maternal IgG from the placenta is hypogammaglobulinemia. Thus it can be transferred to the fetus appreciated how a growing child at different During the postnatal period: The age periods, from before birth to growing infant comes into contact with adolescence, is different from the adult with microbes and depending upon the extent of regard to the nature and quantity of contact (and thus the antigenic stimulation response to infection. that the infant gets from these) immunologic Immunization programs levels rise. The level of immunoglobulins for children increases with the hyperplasia of the lymphoid follicles. It is for this reason that Immunizing children is a form of tonsils and lymph nodes gradually enlarge specific protection against disease. From the with increase in synthesis of time of small pox vaccination to the present immunoglobulins. The passive immunity times tremendous progress has been made that the infant gets from the placenta with in disease prevention with the help of IgG does not last long and vanishes in about vaccines. Research continues in developing three months. The amount of this passively newer, safer and more effective vaccines, acquired immunity depends upon vaccine trials and their final approval for antibodies in the maternal plasma at the general use. Immunizing agents in use time of the transfer. The presence of this currently are vaccines anti sera and passive immunity in the infant interferes immunoglobulin. Each country has a policy with protection provided with vaccines. for immunizing children. Some vaccinations Maternally acquired immunity against are mandatory, as a national policy while individual infections varies so that some last others are optional, left to parents and their longer than others, e.g. against measles lasts physician to choose. Among the six vaccine- till after the first year so that measles preventable diseases are tuberculosis, vaccination should be given later. Immunity diphtheria, whooping cough (pertussis) against pyogenic bacteria lasts only a few tetanus, polio and measles. The WHO months so that related vaccines need to be officially launched the program of given early. These facts thus, determine the preventing these six diseases world vide, in scheduling of various vaccines. IgM, which 1974 under the EPI (Expanded Program of is effective against gram negative bacteria, is Immunization) and in India it was started in not transferred from the mother to the fetus 1978. The program was later renamed so that the baby is susceptible to infection Universal Immunization Program (UIP) and 40 launched in India in November 1985. The additional doses of some of those already vaccines included in the schedule of included by the government and some other immunization recommended by the optional ones the cost of which will not be Government of India are provided free. This borne by the government but by the parents schedule is supplemented by the Indian themselves. See Appendix II for all Academy of Pediatrics and includes immunization schedules.

Immunization Schedule Age National Indian Academy of Pediatrics

Birth BCG, OPV (0), HB (1). BCG, OPV (0), HB (1)

6 Weeks DTwP(1), OPV(1), HB(1), Hib(1). DTwP(1)/DTaP(1), OPV(1)/OPV(1)+IPV(1), HB(1), Hib(1), Rotavirus 1

10 Weeks DTwP(2), OPV(2), HB(2), Hib(2). DTwP(2)/DTaP(2), OPV(2)/OPV(2)+IPV(2), HB(2), Hib(2), Rotavirus 2

14 Weeks DTwP(3), OPV(3), HB(3), Hib(3). DTwP(3)/DTaP(3), OPV(3)/OPV(3)+IPV(3), HB(3), Hib(3), Rotavirus 3

9-12 Months Measles Measles

15-18 Months ----- DTwP (B1), DTaP(B1), OPV(4)/OPV(4)+IPV(B1), MMR(1), Hib(B1)

2 Years ----- Typhoid

16-24 Months DTwP(B1), OPV(4), MMR -----

5 Years DT DTwP(B2)/DTaP(B2), OPV(5), MMR(2)

10 Years TT,HB(B) Tdap/Td

16 Years TT HPV

9, 18, 24, 30, 36 Months. Vitamin A

41 Cold Chain should be given over the antero lateral The process involved in transporting aspect of the thigh. In older children the and distributing vaccines from the point of deltoid muscle can be used for injection. manufacturing to the point where it is stored OPV: When oral polio is administered, and used is called the 'cold chain'. the mouth should be opened by gently Precautions have to be taken to prevent loss pressing the cheeks between the jaws and the of potency of vaccines in this process. Loss vaccine is dropped under the tongue. Breast of potency occurs in warm temperatures and feeding should be done after 15 minutes. therefore vaccines need to be kept at ROTA VIRUS VACCINE: Oral vaccine, appropriate temperatures. administered like OPV. l In large states: Walk in freezers with National Health Programs for temperature monitoring at -20°C children l Other states: Walk in coolers with temperature monitoring at -20°C A large number of programs are l operating in the country at present. Some are Freezers with temperature monitoring entirely funded by the central government at district level stores (-20°C) and others by the center as well as states. l At the PHC's: Ice lined refrigerators Some are working effectively while others and vaccine carriers (at +2 to +8°C) lack funding at state level. Rural outreach l Dial thermometers. varies from state to state particularly where transport and communication need to Lyophilized vaccines such as BCG, improve. Some of the important programs measles and MMR and Polio vaccine need are given below. It is not possible to include to be kept stable at freezing temperature. all details and interested readers are referred Others can be kept at 2-8 degrees to textbooks and other references (Park's centigrade. Adjuvanted vaccines (DPT and Textbook of Preventive and Social Medicine, Hepatitis B vaccine) should not be frozen 20th edition and Indian Academy of and if they freeze they should be discarded. Pediatrics Textbook of Pediatrics). Vaccines should be utilized within the date of expiry indicated by the manufacturer, A) Mother and child care MCH, ICDS, provided the temperature norms are CSSM, RCH, IMCI adhered to. In the clinics vaccines should be B) Communicable diseases National stored in refrigerators maintaining immunization program, ARI control temperatures between 4 and 8 degrees program, Diarrheal diseases control centigrade. After reconstitution, lyophilized program, TB control, Leprosy vaccines should be used immediately. eradication, Malaria/arthropod borne Multidose vials can, at best be kept cold for diseases, Filarial control, Guinea worm another 6 hours but should be discarded control, AIDS, STD control program. immediately thereafter if not used. C) Non-communicable diseases Site of administration School health, Cancer control, Mental health, Drug de-addiction, Diabetes BCG: Lateral aspect of left shoulder, control, Blindness control Pr. intradermal injection. D) Nutritional disorders Nutritional DPT, Hepatitis B. All intramuscular Programs, Mid-day meal, Anemia and subcutaneous injections in infants

42 prophylaxis, Vitamin A deficiency government took the decision to control, Iodine deficiency control expand it to cover large areas in the Pregnancy. country in 1982. Key to abbreviations: MCH: l After 2005-2006, supplementary Maternal & Child Health; ICDS: Integrated nutrition program was assigned to this Child Development Scheme; CSSM: Child scheme which, prior to this was the Survival & Safe Motherhood; RCH: responsibility of the states under a Reproductive & Child Health; IMCI: different program. Integrated Management of Childhood illness Centers of Service: Services provided and IMNCI: Integrated Management of under the ICDS are carried out at Neonatal & Childhood Illness. 'Anganwadi Centers' (AWC's) under a key worker called the Anganwadi worker. A) Mother and child care programs Population norms have been established to 1. MCH program activities set up such centers based on needs, such as rural, tribal, far flung or urban areas such These aim at reducing maternal, infant as: and childhood morbidity and mortality; promoting reproductive health; and For a population of 400 to 800 : 1 AWC promoting physical and psychological 800-1600 : 2 AWC's development of children. Services rendered 1600-2400 : 3 AWC's. include Antenatal care, Care during child In larger populations: I center for birth and care of children at risk. multiples of 800 inhabitants. Key workers and centers of services: For far flung areas, tribal, desert, hilly All staff at Health centers at blocks-Primary etc I AWC for 300-800 population. Health centers and sub centers. One Mini Anganwadi Center is set up 2. Integrated Child Development for a population of 150 to 400. Services (ICDS) program Services provided: To provide a This is the foremost scheme for package of services for children- the human children's welfare in India at present, in resource of the nation. These include: terms of importance, outreach and l Supplementary nutrition coverage. l Immunization (by local health centers) Brief History: l Health check ups (provided by local l Prepared in 1975 health centers) l During 1975-76, 33 projects were l Medical referral as required (provided taken up in urban, rural and tribal by local health centers) areas on experimental basis. l Nutrition and health education to l In 1978-79, the scheme was extended mothers to 100 areas. l Non formal education to children l Evaluations were conducted in 1978 below 6 years and 1982. l Education to pregnant and nursing l Based on satisfactory results mothers.

43 Objectives: Using the infrastructure of the ICDS l Improving health and nutrition of the other services for adolescent girls 11- 18 children 0-6 years. include: l l Help in psychological, physical and Kishore Shakti Yojna social development of the child. l 'Nutrition program for adolescent girls' l Reduction of mortality, morbidity, is implemented. malnutrition and school drop-out l Rajiv Gandhi Scheme for empowerment of adolescent girls l Work towards effective coordination (SABLA) between departments working for promotion of child development. l Indira Gandhi Matrutva Sahyog Yojna. l To improve the competence of (For details look up 'Park Textbook of mothers in the area of nutrition and Preventive and Social Medicine 21st edition health education. p 545) Beneficiaries: 3. Child Survival and Safe Motherhood (CSSM) program Beneficiary Services provided (1992) Children below Supplementary The activities include: antenatal care 3 years nutrition to pregnant mothers (including prevention Immunization of anemia and nutritional deficiency, tetanus Health check ups immunization, identify high risk pregnancy Referral services and appropriate referral); basic neonatal Children 3-6 years All the above and care (including breast feeding promotion Non formal education and education, referral of high risk neonates Adolescent girls Supplementary to higher center) 11-18 years nutrition 4. Reproductive & Child Health Nutrition and health education. (RCH) program 1997 Kishore Shakti Yojna Previous National Welfare Program (see below) renamed as RCH program. Objectives Pregnant mothers Health check ups include: prevention and management of Immunization against unwanted pregnancies; promote safe tetanus motherhood; services to promote child Supplementary survival; supplementary nutrition to nutrition vulnerable groups; prevent and treat Nutrition and health infections of reproductive tract and sexually education. transmitted diseases; education for safe Nursing mothers Health check ups health and sexuality; provide referral services. Supplementary nutrition 5. Integrated Management of Nutrition and health Childhood illness (IMCI) & education. Integrated Management of Other women Nutrition and health Neonatal Childhood illness 15-45 years education. (IMNCI) Integrated management of childhood

44 illness (IMCI) strategy, developed by WHO through the ICDS program. This aims at in collaboration with UNICEF and other providing 300 Calories and 10 grams of agencies in mid 1990's combines improved protein per child below 6 years of age; 500 management of common childhood illnesses Calories and 20 grams of protein to as well as prevention of disease and expectant and nursing mothers; 600 promotion of health by dealing with Calories and 20 grams of protein to severely counselling of feeding and immunization. malnourished children; Vitamin A, iron and This strategy has been adapted and folic acid tablets to mothers during the last expanded in India to include neonatal care trimester of pregnancy. at home as well as in health facilities and renamed as Integrated Management of 2. Midday meal Program Neonatal and Childhood Illness (IMNCI). This was started with the object of raising the nutritional status of primary 6. National Rural Health Mission school children in the age group 6 to 11 (NRHM) (2005-2012) years (classes 1 to 5 at school). It was hoped NRHM is a government scheme that that the program would improve nutrition, aims at providing valuable health care attendance at school and prevent dropouts services to rural households all over the in children from the lower socioeconomic coutnry. It specially focuses on 18 states. Its groups, 'backward', ST and SC classes. The major objectives are : supplement is usually a hot meal with food l Decrease IMR (Infant Mortality Rate) grain component of 100 grams per child per and NMR (Neonatal Mortality Rate). day for 200 days. Alternatively, 5 kg of l Provide access to public health wheat or rice are provided per month per services for every citizen. child for 10 months. Much against hopes, l Prevent and control communicable however, the program has not fulfilled the and non communicable diseases. expectations envisaged for reasons of pilferage, lack of adequate supervision, l Control population as well as ensure periodic shortage of supplies and inclusion gender and demographic balance. of inappropriate beneficiaries. l Encourage healthy life style and alternative systems of medicine 3. Anemia Control Program through Ayush. The beneficiaries in this program are B) Nutrition Programs children up to 6 years of age and mothers who are pregnant, nursing and those who Nutritional deficiencies have high are acceptors of terminal methods and IUD. prevalence in India and national programs The daily recommended dose is as under: mainly address Protein energy malnutrition (PEM), Nutritional anemia, Nutritional Women: 60 mg of elemental iron plus blindness and Iodine deficiency. All these 0.5 mg folic acid interact to increase morbidity and mortality Children: 20 mg elemental iron plus singly and together. Infections worsen this 0.5 mg of folic acid interaction. 4. Vitamin A Deficiency control 1. Special Nutritional Program (SNP) Program Provision of special nutrition to Vitamin A deficiency accounts for mothers and children is now carried out about 10% of blindness in India, and causes

45 night blindness, dryness and softening of the National immunization days (NID's): eyes resulting in blindness. Vitamin A Immunization is carried out all over a given concentrate in a dose of 200,000 units is area of the country on announced days, given orally every 6 months from age 9 when all children below 5 years, irrespective months to 3 years. Breast feeding is of their prior immunization status, are given encouraged particularly the Vitamin A rich oral polio vaccine on that day, under the colostrums in the initial breast milk and global polio immunization program. foods like yellow fruits and green leafy AFP surveillance means surveillance of vegetables. Since measles diminishes iron 'acute flaccid paralysis' cases. Any case of stores in the body, Vitamin A is very flaccid paralysis occurring in a child is necessary for children who are suffering reported promptly and investigated for polio from measles to prevent blindness. virus. Surveillance is carried out by 5. Iodine Deficiency Disorders Surveillance Medical Officers and Assistant Control Program (IDD) Medical Officers who are responsible for Initially this started as the National conducting the survey, investigating and Goiter Control Program (NGCP) In some then identifying polio viruses for further parts of the country, particularly northern action. UP, iodine deficiency is very common 2. Acute Respiratory Infection (ARI) resulting in goiter and mental retardation in control program children. Thus a national program of compulsory iodation of dietary salt was ARI is responsible for up to 30% of all introduced in 1984. The program action deaths in children in India. A large includes survey of endemic areas in the proportion of children are brought to country, supply of iodized salt and outpatient clinics with respiratory infections. monitoring results through resurveys. Recognition and treatment of these with oral agents can be done by paramedical workers C) Control of communicable trained for the purpose. WHO has provided diseases programs guidelines and protocols for this purpose. Communicable diseases Programs exclusively addressed to and benefiting 3. Control of Diarrheal Diseases children Program (CDD) About 25% of deaths in children 1. Universal Immunization below 5 occur mainly from dehydration. Program (1985) The main strategy is its prevention with oral Its precursor, the EPI or the 'Expanded dehydration solution (ORS). Education of Program of Immunization' was started workers and mothers, hygienic measures, globally in 1974 and in India in 1978. The use of clean drinking water are some of the objectives of the UIP are: to increase other aspects of this program. immunization coverage; improve quality of services, production of vaccine, supply of National Communicable Diseases equipment under the 'cold chain' Programs Additionally benefiting requirements, monitoring and training of children: health workers. (For 'Immunization schedule' see p. 41) 1. National Tuberculosis Program (Revised) (RNTCP)

46 2. National Leprosy Eradication record of each student should be available Program with the school authorities. The program 3. National Malaria Control Program was initiated in 1996 but is not carried out regularly as envisaged in all regions of the 4. National Filaria Control Program country, particularly schools in rural and 5. Aids and STD control Program suburban areas (Fig. 18). D) National Programs aimed at The Girl Child in India control of Non-communicable and Dominance by the male sex is well other Diseases known in history but with changing times Apart from the School Health Program and emancipation in the civilized world described below others indirectly. benefit women have increasingly been given their children. due and equal status with men. In some traditional societies and in some regions of National School Health Program the world however, the female continues to A team consisting of doctors, dentists, remain subjected to male dominance, teachers and paramedical workers is exploitation and neglect. deployed on a 3-day camp type approach The status of girls in a community has once in a year for this purpose. They carry far reaching implications- social, economic out examination and any student found in as well as that of health of a nation. The sex need of special attention is referred to a ratio, i.e., the number of females to the male clinic or a hospital and followed up. A population is a good indicator of this status.

Fig. 18 : Examination of a school child at a health check up

47 High ratio (i.e. more males than females) Gujarat and Bihar. The ratio is low in the has been a matter of concern in India as this southern states with Kerala leading, ratio is very disturbing. In 2001 the ratio followed by Tamil Nadu, Karnataka and stood at 933 females for every 1000 males. Andhra. The nature of discrimination The ratio is particularly high in the northern against the female child and its and some western states including Punjab, consequences at different periods of life is Haryana, Uttar Pradesh, Maharashtra, shown in the table below:

AGE PERIOD DISCRIMINATORY ACTION COSEQUENCES Before birth Feticide of unwanted sex High sex ratio and its consequences. Obstetric complications in mother At birth Disappointment. Even infanticide or High mortality rate in the female. High neglect in providing nutritional and sex ratio. Consequent high birth rate to health care ensure survivors Infancy Deprivation, neglect in fulfilling needs High infant mortality, negative impact on such as feeding, clothing, toys, family planning, high consequent birth immunization, health care. Infanticide. rate to ensure surviving children. Childhood Neglect in education, unequal share of High morbidity from deficiency diseases food, clothing, sports, and entertainment. and mortality. Economic loss of rearing Burden of household chores. expenses on parents and the nation, Responsibility of younger sibs consequent on deaths of children Adolescence Increasing responsibilities for household Obstetric and health consequences from chores and younger sibs, childhood early marriage pregnancy and employment in some communities, motherhood. Disharmony cruelty, dowry school dropout; early marriage deaths.

This table (above) shows the plight of the family to supplement the meager family a girl in many communities even before she income. During adolescence she is married is born. Following ultrasonographic away early and is burdened with early sex, determination of sex, the unwanted female pregnancy, marriage and child birth when fetus is aborted. At birth, neglect in she is hardly prepared for these. The nutritional and health care, results in consequences are high rates of sickness and malnutrition, sickness and even death. death. Available figures indicate higher There is gender discrimination in the share mortality in girls than boys, higher school of food, clothing, entertainment, toys and dropouts and poorer literacy rates. education. As the girl somehow grows up Aware of these disturbing trends the she is entrusted with household chores, government has initiated certain actions and often hard and tiring, care of younger sibs incentives to encourage birth, health care and thus deprived of time for school, and education of girls but more is called for. recreation and entertainment as against her Unfortunately the social order in certain brother who has all the advantages. Apart communities is such that females themselves from physical neglect, the child is subjected contribute to the plight of girls like the desire to emotional trauma as a result of this stark to have sons. A mother without a son often discrimination. She may have to earn for suffers from social ostracization.

48 Traditional practices in child care. delayed or denied to child in time to Some popular attitudes and beliefs save his life. in child rearing. l Practices of which too little is known Children are born into families and whether they cause harm or are families make the community. Each harmless. These may include swinging community has its own customs, beliefs and children in hammocks, hand feeding, attitudes handed down from one generation baby massage by mother etc. to the next. A health worker, be it a The action required in each case is physician, a nurse or a paramedical worker, that a beneficial practice should be who works with children, must know these encouraged, a harmless one ignored, the as they relate to pregnancy, birth, child harmful practice tactfully explained and rearing and to sickness and death. A nurse discouraged. The unknown practices should herself should know certain beliefs and be carefully studied and discussed with customs from her own community, but if the colleagues and if sufficient experience is working in another region or community indicates, this last category should be she must be aware of traditions of those she grouped into one of the other three. is serving. Customs and beliefs are deep No list of customs and practices can be rooted and no effort should be made to complete. We need to learn from parents contradict these so long as these are not and relatives, while we work in the harmful. A health worker comes to know of community, about newer ones that may not new practices with experience and should have come to our notice before. Some make a note of a new custom, practice or common beliefs and traditional practices are attitude she comes across, study it and then listed below: group these in to one of four groups: Beneficial practices and beliefs: l Beneficial practices such as demand breast feeding, Anna prasan, close l Prolonged breast feeding contact of mother with baby and l The ceremony of first introduction of carrying the baby to work on her back semisolid foods called 'anna prasanna' in some tribes. l Mother infant bonding through close l Innocuous (harmless) practices such as contact with mother whether at home wearing amulets, charms, Taweez, etc or at work, especially in tribal l Harmful practices such as use of kajal societies, carrying baby on back. in the eye which may not be clean; l Indigenous baby walkers (wooden practices of traditional masseurs tripods mounted on wheels) (malish wali) who squeeze the breasts l Living in joint families ensuring round of a newborn baby in the belief that the clock attention and stimulation of the secretion is harmful and should be baby's development. expressed, the practice of hasli bithana l etc. Food fads like 'hot' and 'cold' Avoiding baby bath for some duration. foods can be harmful if the child is l Wrapping premature babies in cotton deprived of nutritious foods, or wool to prevent cooling. starved in febrile illnesses. Jhad Phoonk may not be harmful in itself Harmful practices and beliefs but can be so if urgent treatment is l Diarrhea is often attributed to teething

49 l Purgation to 'cleanse' the bowel effects -biological as well as social and l Use of Kajal which may be unhygienic demographic. The average age of marriage in 1951 was 13 years in India. l Belief in 'hot' foods like egg, meat, onion etc. Legislation: As early as 1929 the l Sharada Act (Child Marriages restraint Act) Foods said to cause cold such as was enacted to forbid child marriages. banana, Dahi, rice, milk etc. Despite this and improved literacy however, l Sweet foods and sugar as cause of child marriages continue to be performed. intestinal worms. In 1978, the Child Marriages Restraint Act l Restriction of food and fluids in illness, was passed raising the legal age of marriage particularly fever. to 18 years in girls and 21 years for boys. This act was repealed in 2006 and the l Taking the witch doctor's advice (Jhad Prohibition of Child Marriages Act enacted Phoonk) when the child is in need of in order to 'prohibit' child marriages rather emergency or critical care, thus than only 'restraining' them. With effect from delaying life saving management. By 2007 this last act has been enforced making itself this is otherwise harmless. such marriages a legal offence with l The traditional female masseuse provision for punishment (malish wali) who visits homes where a baby is born, to provide her services. Handicapped Children. These often include dangerous l Definition of handicap: Presence of maneuvers such as squeezing baby's impairment or other circumstances breasts for 'harmful' secretions, hasli that are likely to interfere with normal bithana, treating chor dant etc that growth and development or the result in complications. capacity to learn. (Last J.M (1995), A l Branding a child's abdomen for relief dictionary of epidemiology Oxford of symptoms University Press.) l Classification: Practices for which too little is known v Physical handicap- l Driving away evil spirits (nazar utarna etc) - Due to birth defects: Such as congenital heart disease, l Use of charms and amulets to ward off talipes, congenital deafness/ evil spirits mutism, blindness etc l Massage of baby by mother. Indeed - Infections: Poliomyelitis etc this may help in bonding but its true value is not clear. - Accidents: Road accidents, burns, poisoning etc. Social issues relating to children v Mental handicap- in the community - Due to: Genetic defects such Child marriage: as chromosomal (Down's Traditionally, the custom of early syndrome), metabolic marriage has been prevalent in India for (Phenylketonuria) storage ages. It is still prevalent in many regions of disorder (Tay sach's) etc India. Early marriage has a number of ill - Antenatal factors: such as 50 maternal infections accidental injury', among broken, divorced (TORCH group of or teen age parents, alcoholic parents with infections), irradiation, and unwanted or so called 'illegitimate' children, drugs during pregnancy. is a global phenomenon and is not confined - Perinatal factors such as to the poor alone. birth hypoxia, blood group Reasons: incompatibility and their l Unwanted children consequences. l Teen age marriage and early birth of - Acquired factors like head babies injury, encephalitis, l meningitis. Divorce. l v Social handicap- Accusation of infidelity/ offspring out of wedlock. - When, due to harmful social l factors such as broken Broken home. family, death of parent, l Social deprivation, poverty, alcoholism homelessness,displacement, of parents emotional deprivation, lack Remedies: of opportunity to learn and l play, a child does not grow Extensive home visits by Public health to his full potential and is nurses and other health workers and exposed to criminal welfare agencies, by way of supportive activities, association with care among families 'at risk' to prevent gangs, drug abuse, begging, child abuse. prostitution, and so on. l Preventing teen marriages and Since the magnitude of the problem is pregnancy. enormous, child welfare activities through l Educating and helping young parents government and non government agencies, to postpone having babies. individuals and other philanthropic agencies l need to be developed and rapidly expanded Vocational support to unemployed with expertise in each area of activity. parents. l Legal help as required. Child abuse: Definition: Physical, sexual or Child labor: emotional maltreatment and exploitation of Broad definition: No specific definition children. has been laid down. However, taking Magnitude: This has been an age old account of an International Labor phenomenon in history. Precise figures are Organization (ILO) convention passed in not known but an approximate global 1973, employing children below age of 15 estimate indicates that about 2 per cent of years in labor activities that are all children are subject to physical and social inappropriate for their age and physical abuse. Children have through ages, been strength and interfere with their adequate victims of all kinds of abuse and subject to physical, mental and social growth could maltreatment, neglect and deprivation. broadly be considered as child labor. Light Battering of babies, also labeled as 'non work from the age of 13 years is permissible 51 provided that such work is unlikely to harm Street Children: the child's, health, morals or safety or Broad Definition: Children forced by prejudice his school attendance. circumstances to live and work on the Magnitude: India has the largest streets. number of children in employment in the Magnitude: Estimates indicate that world. Surveys by ILO (1990) indicate that about 25 million children (2.5 crores) live globally, over 79 million children under 15 on the streets in Asia and global figures years were in the work force. Estimates for approximate a hundred million (about ten those in domestic services are not available crores)! These children live mostly on the but include a substantial number, streets of large cities. particularly girls. Reasons: Death from disease / Reasons: Compulsions for earning a breakdown of families, poverty, physical livelihood as a result of poverty, broken or and sexual abuse at home, urbanization, displaced families, destitution, wars and displacement as a result of riots and wars, riots etc. About 20 percent of India's gross natural disasters. national product comes from child labor! Hazards: Involvement in illicit drug How employed: Varies with regions pedaling, drug/ alcohol abuse, crime, and local demands. Most common are prostitution, and diseases particularly from domestic service, carpet weaving, unhygienic living (skin infections like agriculture, mining, road and building scabies, sexually and environmentally construction, garbage picking, beedi transmitted diseases, HIV) making, cloth weaving, dyeing and glass Remedies: Welfare schemes blowing industry and in a large number of (Government or NGO's) aimed at providing other hazardous employment. a shelter or home, food, clothing, school Remedial measures: Apart from education, vocational training and enactment of laws and their enforcement, appropriate employment, expanding and social awareness of public responsibility outreach and providing welfare services as through education, it is necessary to expand far as possible and employment. and continue extensive welfare work by government and nongovernmental agencies. Child trafficking: The task is uphill but rewarding. Broad Definition: Exploitation of Legislation: The Child Labor children after removing them from their (Prohibition and Regulation) Act 1986. This homes by criminals by forcible abduction, act prohibits work in occupations concerned trickery or seduction with promises of with : Carpet weaving, transport of goods or earning. Exploitation includes cheap or mail by Railways, cinder picking, cleaning bonded labor in agriculture, mining and ash pits, cement manufacture, building other industry, recruitment for militancy, construction, cloth printing, dyeing, prostitution, begging, smuggling, robbery or weaving, matches and fireworks drug pedaling. They are often separated, far manufacture, Beedi making, mica cutting, from their homes, often across borders, abattoirs, wool cleaning, printing, cashew away from any help from home, village or descaling and processing, soldering in town to provide cheap labor. electronic industry. Magnitude: Over 8 million children

52 serve as bonded laborers and such other l International Union for Child Welfare. bondage the world over. Placements for children: Remedies: These include preventive action by way of protection of children in To provide some sort of a shelter or families and education. Those away need to 'home' temporarily for a child who is be rescued and then rehabilitated within separated from parents, displaced as a result their country and community. To fight child of disasters, juveniles involved in crime or trafficking a scheme ('Ujjwala') has been for corrective measures of delinquents. launched by the Ministry of Women and These placements may include: Child development in 2007. It mainly l Foster homes where children are put involves NGO's and includes prevention, under the care of willing, unrelated, rescue and rehabilitation. It provides for foster parents temporarily until the reintegration and repatriation of those reasons for such care are no longer particular children who have been exploited operative, such as when the crisis or for commercial sexual exploitation. illness in the child's own family is over or the circumstances for which the Child Welfare Agencies: child is placed improve. The child is A number of national and then reunited with his parents and international agencies named below and cannot be claimed for adoption. many others are engaged in child welfare l Adoption: When a child needs to be activities: permanently placed, a willing family Agencies in India getting grant from may legally adopt the child with all the government: legal rights to the child and the l Indian Council for Child Welfare adopting parents, as with natural l Central Social Welfare board parents. l l Kasturba Gandhi Memorial Trust Orphanages: Homeless children or l when parents are unable to care for Indian Red Cross Society the child, placement in an orphanage These agencies conduct Day Care is considered. However, this placement Services, Balwadis, Holiday Homes, has disadvantages in that the child Recreation facilities which organize play does not get love and intimate centers, public parks, children's libraries, attention so necessary for adequate Balbhawans, national museums, children's physical, mental and social growth, in films, etc. view of the large number of children International Agencies involved in required to be attended to. Foster care Child Welfare in India: is definitely a better option if available l and possible. UNICEF (United Nations Children's l Emergency Funds) Remand homes: These provide l medical, psychiatric, primary WHO (World Health Organization) educational and vocational care for l CARE, (Children's Care Everywhere) necessary correction of erring or India. delinquent children who cannot benefit l FAO (Food and Agriculture from routine schooling. Recreational Organization) facilities and learning of arts and crafts

53 encourage learning a vocation. of children) Act 1986, 2000 and amended - l Borstal homes: These schools are 2006: Provides for rehabilitation of meant for corrective placement for delinquent juveniles and children in need of those delinquent children over 16 care and protection. See below. years who are difficult to be handled Child labor act 1986 (prohibition and in regular schools or are in conflict regulation) relates to prevention of with the law. Since the law is against employment of children in the labor force. putting them into prison, they serve (Also see under 'Child Labor' above). sentences, usually not exceeding 3 Child Marriage Restraint Act 1978: years in Borstal homes. They are Restricts marriage of young boys and girls under the administrative control of the below a certain age. In 1978, the Child Inspector general of Prisons and are Marriages Restraint Act was passed raising not covered by the Children's act. the legal age of marriage to 18 years in girls Child Welfare and related and 21 years for boys. This act was repealed in 2006 and the Prohibition of Child legislation Marriages Act enacted in order to 'prohibit' Children's Acts: child marriages rather than only 'restraining' Children's Act 1960, amended in them. With effect from 2007 this last act has 1977: relates to care, welfare, educational been enforced making such marriages a and vocational rehabilitation of socially legal offence with provision for punishment handicapped, abused or delinquent Hindu Adoptions and Maintenance Act children. It covers the neglected, destitute, 1956 covers legislation in respect of socially handicapped, victimized and marriages among Hindu families. Laws vary delinquent children. This is in consonance from country to country. with the Article 39(f) of the constitution of (For those seeking details please refer India which provides that "the state shall, in to books on Community Health (Park K, particular direct its policy towards securing 21st edition 2011) Textbook of Preventive that childhood and youth are protected and Social Medicine, M/S Banarsidas against moral and material abandonment". Bhanot Publishers and relevant forensic Juvenile Justice (Care and protection texts).

54 History and Physical 6 Examination

This section deals with: winter and cool in summer. l Child friendly examination room l The seating should be comfortable for l Equipment needed for physical children, attending parents and the examination of children. staff working in the clinic. l l Child friendly wards There should be a light above the l Hospitalisation of children examination couch to enable a good view during the examination. l History taking l The waiting room should provide toys l Approach to physical examination and games for children, drawing l Physical examination- general and paper, pastels, and color for older systemic. children and books for school children l Developmental examination (see p 25 and adolescents. Magazines and & 27) newspapers could be provided for l Restraining techniques in the waiting parents. examination of children l Chairs for mothers should be As a doctor, you will often be with your comfortable and the seat level lower doctor colleague, interrogating, examining, than the knees while sitting. This and caring for children in a clinic, hospital, enables mothers to hold the baby in health centre or at a patient's home. Nurses her lap without tiring while waiting for or doctors do not work alone but provide her turn. care as a team, each with his/ her role in the l The curtains, walls and sheets should team. preferably have nursery motifs printed on them. The child friendly l Separate arrangements should be examination room made for nursing mothers to breast l Examination of children requires feed their infants in privacy if they so differing arrangements based on age demand. By and large however, most differences. For example an infant can mothers of rural origin or those in the be examined in the mother's lap and lower socioeconomic classes do not an adolescent will need a couch. An hesitate in feeding their babies in examination room must cater to the public places. needs of children and the convenience l Examination equipment, injection of both, the attending children as well material etc, which is likely to frighten as the medical and nursing staff. young children, should be kept away l The examination room should be well from the child's direct sight. lighted and ventilated, pleasant and l The toilets should be child friendly in inviting, clean, reasonably warm in that the seats, wash hand basins, taps and towel racks etc should be at a the care of her child. In such situations lower level to enable children to access therefore, mother's requirement for her stay them easily. have also to be met like space for night stay, bath and changing, food and so on. Wards/ Equipment required rooms need to be adequate, clean, well for examination ventilated, lighted and pleasant, attractive 1. Stethoscope and provide for separate rooms for examination, procedures, temporary 2. BP Apparatus with different sized cuffs isolation, treatment, pantry/kitchen, dining for children room, play room, waiting and recreation for 3. A good torch visitors. Books and appropriate toys should 4. Auriscope with (handle and ear pieces) be available. Some hospitals provide teaching facilities for school going patients 5. Ophthalmoscope who miss their schooling if prolonged 6. Tongue depressors hospital stay becomes necessary for full 7. Gloves and finger stalls recovery. 8. Glycerin for rectal examination Hospitalization of children: 9. Tuning forks, (for hearing testing and In the event of need for testing vibration sense) hospitalization, certain situations need to be 10. Patella hammer, pin and cotton wool understood and certain requirements met by for testing sensation children, their parents and the hospital staff. 11. Measuring equipment: height These include: measuring board (Fig. 6), infantometer l Separation of parents from children, (see Fig. 7), weighing scales preferably and the resulting trauma, however beam balance type (Fig. 4), fiberglass mild and brief, particularly in measuring tape, 'test size' for circumstances where parents do not or measuring testicular size (see Fig. 10) cannot stay with their children. The 12. Equipment for development response of the child varies with age of assessment: colored one inch cubes, the child and the duration of bell, colored pictures, pencil, pastels separation. and paper etc. l Preparation of the child for The Child Friendly Children's wards. hospitalization, removing fear and Because a child has to stay in the providing support by parents and hospital for certain duration, particular care friendly hospital staff, particularly for a and a certain amount of sensitivity has to be diagnostic or an operative procedure exercised in making the stay pleasant for the l Adjusting to a new environment, child and his mother, who is often allowed situations and various hospital to stay with her child in India, in view of personnel. limited number of personnel particularly l Provision of recreation for the child nurses. The advantages of allowing this are that it eases pressure on the nursing staff, through toys, games. provides emotional support to the sick child l Provision for parents to stay with the and the mother and educates the mother in young child especially below 5 years.

56 l Acceptance of and adjustment of general election, the year of parents to hospital routines and earthquake, and the death of a regulations national leader and so on. l History taking History of present illness: Let the mother first give her account of the A carefully taken history contributes child's illness. After carefully listening substantially to diagnosis of an ailment. A to her, ask leading questions to fill up young child cannot express itself. The the gaps. Nature duration and severity mother, who understands her child, his pain of each symptom described should be and feelings well is available always by the sought. A good habit is to first listen, side of her child to answer the nurse's make queries and then write so that queries. Of all attendants who may the mother and not the notes appear accompany a child to the clinic or hospital, to be important to her. The events the mother is most reliable. Sometimes should be recorded in chronological father alone or both parents accompany order. Knowledge and skills learnt by while at others the child is brought by a experience help to pick up the grandparent, uncle or even a friend. Persons essentials and discard the trivial. other than the parents cannot often provide l details of history, particularly those related Family history: Parents' health, age, to pregnancy, birth, feeding, development, number of children alive, cause of past history etc. death of any sib, stillbirths, abortions, family planning (and contraception Before seeking information, it is procedures carried out), genetic necessary first to establish rapport with the disorders, allergies. person providing history. It should start with l a welcoming smile to establish good Pregnancy and labor: Preterm or communication with the informant. The full term; mother's diet and health; desire to help should be genuine and illness particularly if any, birth weight, obvious. suckling and swallowing, history of cyanosis fever, rash, edema, urinary or l Age should first be calculated from the other specific illness; drug intake, date of birth. Educated parents can irradiation like x ray. Delivery at home provide this but our rural and or in the health centre or hospital; undereducated folks have difficulty in obstetric interference required if any, producing this information. With some type of labor. efforts however, this can be found out. l India is a country of festivals, religious Birth history: First cry, immediate or and other. If we have the local delayed, vigorous or week, calendar, the month of birth can be resuscitation carried out if any, birth found out with some margin of error. weight, suckling and swallowing, The problem however, is the year of cyanosis, jaundice. birth, but this too can be determined l Developmental milestones: Ages at with a 'calendar of events'. It is which baby was able to hold neck, sit possible to prepare such a calendar up, crawl, stand, walk, talk etc. to based on local or national events, such ascertain if development was normal or as the year of drought, the year of regressed after progressing normally.

57 l History of diet: Length of breast l Calm, gentle and compassionate feeding, age at which top milk started, approach is an essential attribute quantity given, bottle, spoon, cup used required of a nurse caring for children. for feeding, age of starting semisolid In order to be successful, you need to (weaning) foods, nature and quantity. love children. l Immunization history: When and l There is no fixed order of examination what vaccinations given-BCG, OPV, of a child. This has to be improvised DPT, Hib, Hepatitis A , Hepatitis B, during examination, with the child's Measles, MMR, Chicken pox, typhoid mood and convenience. The sequence etc. Whether schedule followed and of examination should thus be defaults if any.. Most children now get determined by the child rather than mandatory vaccinations required the examiner. under the national programs and l Avoid being brusque or in a hurry, this include BCG, DPT, OPV and Measles frightens children. Keep the mother but others are optional and given at close to the toddler so that he feels the discretion of parents. secure. He may feel comfortable holding his mother's hand. l Past illness: Age at which any illness occurred, particularly common l While examining give a running childhood illnesses. History of commentary, praise the child and hospitalisation and its details. distract his mind from the examination. The conversation may be l Socioeconomic details: Economic about his clothes or a toy and so on. background; approximate income This keeps the tears at bay. group; whether one or both parents employed; Level of literacy and l The examination should appear as education; living standard (including though it is a game you are playing size of house, source of water, sanitary with the child. An older child can be conditions particularly toilets, sewage engaged in a conversation about disposal etc); purchasing capacity, school or his favorite sport and so on. especially for food, medicines and The examiner should say what he is other essentials; faith and religion in going to do next. relation to child's illness. l To keep an infant quiet and l School performance: whether cooperative, he could be fed glucose attending school regularly; in a bottle or put to mother's breast as performance in studies; sports; many mothers in India will agree to do interests. this while she covers the baby's head. l Any painful procedure, like Physical Examination examination of the throat or ears, Approach which might make the child cry, should be done last. Unlike in an adult, physical examination in children needs to be flexible l Adolescents are sensitive especially and take into account certain approaches to with regard to examination of the adjust to the age dependant needs of the genitals and reluctant unless tactfully child. These are: handled and taken into confidence. A

58 pubertal or adolescent female must be abnormality in any manner? examined in privacy in the presence of l Body proportions and general mother or a female attendant. If appearance like wasting, obesity or required to remove her clothes, she short stature, disproportionate body should be examined wearing a gown segments, limb length etc, deformity, and exposed partially, examined part abnormal posture. by part, exposing only the part l required to be examined at a time. Facial features can be made out such l as cretinism, moon face, open mouth Do not make any notes while and nasal obstruction ('adenoid examining the child. This can be done facies'), sunken eyes of dehydration, at a convenient moment on 'mongolism', microcephaly, completing the examination. hydrocephalus, abnormal movements Measurements: (see p 17-21 under or facial paralysis and so on. growth and development) The weight and l Skin should be seen for pallor, height plotted on the growth chart should be jaundice, cyanosis, or edema. available before the examination. In l addition, circumference of the head is Chest is observed for fast or irregular important in the case of infants and younger breathing, nature of breathing, in children. In special situations, we may need drawing of ribs, and any sounds noted to measure the sitting height and obtain the such as stridor or wheezing, lower segment length by subtracting it from paradoxical breathing (see below). the total height or length i.e. what is called l Abdomen for distension, visible veins, the ratio of upper to lower segment or CR: any mass, peristalsis, abdominal wall RH ratio (Crown Rump to Rump Heel edema, hernia etc. ratio). This is required in certain disorders of l Limbs are seen for muscle wasting, short stature. Another measurement is the loss of subcutaneous fat, pallor, Span length, which is the length from finger jaundice, edema, cyanosis clubbing, tip of one hand to finger tip of the other in rash and its distribution, clubbing of the outstretched hand. fingers, pettechiae, abnormal posture General Observations: From the or inability to move as in paralysis. moment the child enters the room with the l Gait is observed for limp, ataxia, mother, observations should start without paresis, spasticity, Observations begin making the child conscious that he is being while the mother is being interrogated watched. Such careful observations can and can continue during general and yield considerable information without systemic examination. disturbing the child. l The child's personality can be General physical examination determined to an extent, for instance This includes vital signs (PTR, BP), does he cling to the mother, is he shy, face, head, lymph nodes, mouth, ears, nose, quiet and silent, apprehensive or bold throat, skin, bones and joints, spine and and aggressive, is his speech clear etc. genitals. Actual examination should follow l Does his behavior appear to suggest and accompany a good observation as mental alertness or dullness or discussed above.

59 Vital signs (PTR, BP). takes five minutes. One thermometer l Radial pulse rate can be counted in reading may be enough to make a older, cooperative children. For infants casual observation but round the clock and children, heart rate can be charting is necessary to come to a counted with the help of the clinical conclusion regarding nature of stethoscope. Its rate, rhythm, volume, fever of some duration. This can be and amplitude are noted. Some done four hourly or in some special irregularity normally occurs in infants situation, more frequently. The axillary and younger children, (sinus (arm pit) temperature is 0.5°C, lower arrhythmia) with respiration (increase than the oral while the rectal or in the in rate during inspiration and ear (with thermo-scan) is 0.5°C higher diminution in expiration). Femoral or than the oral. Parents often complain carotid pulse can be counted more that the child has fever because his easily as these are larger vessels. The forehead or hands and palms are difference between heart rate at the warm. This is normal in children but apex and pulse rate is called the pulse any doubts should be cleared with deficit and is significant in certain measurement. Such children are often cardiac conditions. For each degree subjected to unnecessary antibiotic rise of temperature (Fahrenheit), the and other therapy which can easily be pulse rate increases by 8 to 10 beats avoided. per minute. l Respiratory rate in an infant is l Temperature can be measured in the counted watching the respiratory mouth, only in older children and movements of the abdomen in one should be avoided in toddlers where minute. The rate varies largely with axillary temperature can be measured. age as shown in the table below: Rates If the glass thermometer breaks in the higher than the normal call for mouth it can cause mercury ingestion investigation into heart and lung and poisoning. Armpit or groin disease in particular. Nature of temperature should be measured for 5 breathing is noted in respect of minutes. Rectal temperature is more rhythm, in drawing of ribs, prolonged reliable but should be confined to and forceful expiratory phase as in more serious situations. Several other asthma, 'paradoxical' breathing' sites and instruments are available for (epigastrium falls in with each measuring temperature. These include expansion of the chest) seen in the thermo-scan for ear temperature diaphragmatic paralysis. Heart and which takes one second and is based respiratory rate have a certain normal on infra-red technology. Strips are ratio which is disturbed in certain used for measuring skin temperature at conditions. In an adult, for instance, the frontal bone site but these are not there are about 4 to 5 pulse beats for accurate. Digital thermometers are less each respiration, considering a normal suitable for children because they are adult pulse rate of 72 and respiratory programmed to signal the temperature rate of 16 to 18 per minute. Any gross in half a minute while reliable deviation in this ratio should be measurement of axillary temperature investigated.

60 AGE Respiratory Heart Rate 'Mongolism', Gargoylism, In Rate per minute hypertelorism. Look for asymmetry, yrs. per minute (Av. Range) dysmorphic features, or anything that appears odd like open mouth, At birth 40 70-120 'adenoid facies'. A large number of At 1 30 80-160 congenital and chromosomal At 5 20 75-120 abnormalities can be seen, all of which At 10 18 70-110 cannot be described here. A look at Above 10 16-18 Adult 72 any good atlas of Pediatrics will show different appearances. l Blood pressure: In older children and l Eyes: Look for subconjunctival adolescents, it can be taken as in the hemorrhage, pallor of conjunctivae, adult. In younger children (toddlers ptosis, meeting or bushy eyebrows, and infants) certain special techniques long curvy eye lashes, cataract, are employed. The BP can be reliably coloboma (partial absence of iris, or recorded by Doppler technique. Using other parts of eye), exophthalmos the usual BP apparatus and cuff, the (hyperthyroidism), heterochromia cuff should cover two thirds of the (difference in color of iris in the two upper arm. Three different sizes are eyes). Sunken eyes occur in available for the pediatric age group. dehydration. BP of both upper and lower limbs l should be taken. For the diastolic Any swelling like that of parotid glands pressure the point at which Kortakoff (mumps), glands in the submandibular sounds become low pitched and area, pigment disturbance of the facial muffled is taken rather than skin, acne in adolescents etc disappearance of these sounds as in Head: the adult. In infants BP cannot be taken l by the ordinary technique. The Flush Size and shape of skull. Too large or Method measures the systolic BP thus: small (micro or macrocephaly), BP cuff of appropriate size is wrapped detected from more than 2 standard round the upper arm, the arm is raised deviations from the mean as indicated vertically and kept so for a while till the on standard graphs (see Appendix I). hand turns pale, the cuff is inflated Premature closure of sutures Synostosis approximately to a level higher than leading to abnormal shape of skull will expected, and then gradually brought depend on which suture is prematurely down to the chest level, the cuff is then closed, such as scaphocephaly (boat deflated slowly and the point at which shaped skull), dolichocephaly, the hand gets flushed marks the systolic (increased antero posteriorly), BP. Separate charts are available giving brachycephaly, (decreased antero percentiles of diastolic and systolic posteriorly), oxycephaly, (vertical pressures at different ages in children growth of skull), plagiocephaly (gross (see Appendix I p. 317 & 318) asymmetry of skull). Hydrocephalus can be made out from Face: transillumination test. Increased l Examination of the face can provide lucency can mean hydrancephaly, many clues for diagnosis such as subdural effusion, subdural hematoma 61 or porencephaly. Look for fontanelle, whether closed or, bulging as in Hyoid Bone Sternomastoid meningitis or any condition with raised Muscle Thyroid Cartilage intracranial pressure. In the newborn Cricoid Cartilage Thyroid look for hematomas under the scalp Gland Lobe Thyroid such as cephalhematoma or caput Cartilage Clavicle Isthmus succedaneum. Bone Manubrium Neck: Sterni l Arterial and venous pulsations. Palpate Fig. 20 : Neck structures thyroid gland. Any lymph nodes in the l submandibular, posterior cervical, Ears for wax and cleanliness; discharge if any. Auriscopic examination of a occipital and other areas (See Fig. 19 child is a must, particularly if a child & 20). Any cysts, fistulae or masses. has an upper respiratory infection, for Palpate trachea if it is central. Short or visualizing the ear drum. (See Fig. 22) web neck, torticollis. Upper Lip

Upper Incisors

Hard Palate Uvula Preauricular Soft Palate

Tonsil Submental Sublingual Duct Occipital Opening Frenulum of Tongue Submandibular Post Auricular Submandibular Duct Opening Under suface of raised Superficial Cervical Tongue Lower Incisors Deep Cervical Lower Lip Fig. 21 : The oral cavity Fig. 19 : Lymph nodes in the neck l Nose should be inspected for any Mouth ear, nose and throat: deviated septum, turbinates for l Look for mucous membrane over the hypertrophy, blocked passage and lips, tongue, buccal surfaces, palate secretions. A deeper look can be taken and throat for any ulcers, patches, dry with a nasal speculum for any bleeding and indurated areas. Gums and teeth spots as in epistaxis. (See Fig. 23) for dentition, erosion, bleeding etc. Tempopralis Lips for cheilosis, cyanosis, ulceration. Muscle (See Fig. 21, 22 & 23) Vesibular Semicircular Helix Nerve Canal l Throat should be examined with a Cochlear Nerve spatula (tongue depressor) for mucosal Pinna of Ear External Canal congestion, particularly pharyngeal. Ossicles Tonsils are larger in children than in Cochlea Tympanic adults till after puberty. Any patches or Pharynx Membran Eustachean Tube areas of granularity or follicles over the tonsils should be observed. Fig. 22 : Section of left ear 62 Frontal Air Sinus Hard Palate Pituitary Fossa

Superior Sphenoidal Sinus Nasal Cavity Middle Sphenoid Bone Conchae Inferior Pharynx

Oral Cavity

Auditary Tube Opening into Pharynx Tonsil

Fig. 23 : Nose and neighboring structures

Skin, hair and nails: genitals if precocious, Tanner sexual l Skin is delicate in children. Look for maturity rating (see Fig. 13 p. 24) texture, skin color, pallor, jaundice and l In girls, labia, vaginal opening, cyanosis. Skin lesions should be redness, itching, clitoris, hymen. carefully described in terms of Sexual maturity rating (Tanner). Any pigmentation, maculae, papules, ambiguity like a large size clitoris, skin pustules furuncles or abscess; blister fused with rugosity resembling scrotal type lesions, pettechiae, bruises, cysts skin etc, and tumors, birth marks, burns and Bones and joints: scars, hemangiomas etc. (See p 301- l 304) Their site and distribution should Bones: Deformity if any, like bowing of legs and enlargement of wrists be recorded. (rickets), scoliosis, kyphosis or lordosis l Hair: Look for pigment loss as in of spine, flat feet; congenital anomalies malnutrition, scalp infection, dandruff, like polydactyly, absence or shortening lice, alopecia etc. of any bone or part of limb; dactylitis, l Nails are observed for cyanosis, bone tenderness as in osteitis and clubbing, pallor, fungal infection osteomyelitis; bone tumors. (onychomycosis) and ridging, l Joints: swelling, pain on movement, spooning (koilonychia), flattening swellings near or around the joint, (platynychia) arthritis- if confined to one joint or several joints. Genitals: l In boys, scrotal sacs, testes and penis. Systemic Examination Any ambiguity; hydrocele, hernia, After a careful general examination, enlargement, hypo- or epispadias, each system, viz. respiratory, cardiovascular, tight prepuce, phimosis, infection alimentary including abdominal under the skin, balanitis. Size of examination and the central nervous system 63 and skin are examined. Again, the approach round in circumference and with growth has to be according to the child's increases transversely so that anteroposterior convenience. An infant should be examined diameter is smaller than transverse. Also the in the mother's lap, an older child, as much chest is narrower in front than at the back. as possible in sitting or standing position The chest is divided into areas for near the mother and an older school child convenience of description, by drawing and adolescent on the examination couch. vertical lines from fixed points and these are: Adolescents are sensitive especially with Front of chest: (See Fig. 24) regard to examination of the genitals and Midsternal line through middle of reluctant unless tactfully handled and taken sternum (1) into confidence. Midclavicular line from the middle of It is not possible to include details of the clavicle (2) examination in a book of this size. Here only brief summaries will be provided. Anterior axillary line from the top of Readers are referred to reference books on the anterior axillary fold (3) clinical methods for detailed explanations Side and back of chest: 1. The Respiratory System Midaxillary line from midpoint of axilla Look at the thoracic cage. Note the Behind the chest the lines are drawn important bony land marks- the suprasternal from posterior axillary fold (4) notch, the manubrium, xiphisternum, Midscapular line from the tip of the median and lateral ends of the clavicle, the scapula (5) thoracic vertebral spines at the back, the Midvertebral line through the middle seven true ribs ending anteriorly at the of the vertebral column (6). sternum, five false ribs ending in front with the true ribs above them. The last two ribs are Inspection: Look for any visible 'floating' in that they are not attached in front abnormalities/ deformities to any structure. In infants the chest is almost l Rickety rosary of rickets: knoblike

Fig. 24 : Lines showing demarcation of regions of front and back of the chest for recording findings of inspection, palpation and ausculation

64 enlargement of junction (rosary) made the so called 'Adam's apple', a prominence by the ribs where they join the sternal above the sternal notch. cartilage (costo chondral junction) Palpation is carried out with the l Pigeon breast (pectus carinatus) is a fanned out hand with the thumbs meeting deformity where the sternum is and fingers spread out, placed on the chest, projected forward resembling the in an orderly manner starting with the front breast of a pigeon, seen in rickets, of the chest, sides and the back. Movements chronic upper respiratory obstruction of breathing are observed for equality on l Barrel chest where the chest the two sides. Diminished movements on circumference is like a regular circle one side indicate that the lung is not expanding on that side. This happens with and occurs in chronic lung pathology obstruction of air entry into the lung like asthma etc. through the bronchus on that side. The child l Harisson's sulcus is a vertical groove is asked to count and the voice is felt with along the lower border of chest seen in the palpating hands. This is called the rickets. 'tactile fremitus'. The sound vibrations are l Local bulging in the chest occurs in stronger above in front and back and certain areas like aneurysm, become weaker as palpation is done away enlargement of the heart etc. from the larger air passages, above downwards. Any significant involvement of The chest can appear deformed in the lungs like pleural effusion, pneumonic deformities of the spine like scoliosis and consolidation, emphysema can be felt by kyphosis. Scoliosis is abnormal sideward the palpating hands. For instance the bending of the spine towards either side and vibrations of the sound the child is making kyphosis is forward bending are reduced over an area of pleural effusion, Palpation: The larynx, trachea, pneumothorax or emphysema. The same bronchi and the lungs form the lower sound heard on auscultation with a respiratory tract. The larynx can be stethoscope is called 'Vocal fremitus" The visualized through the laryngoscope and this palpating hand feels for: any odd eminences procedure is best left to the expert. From the or depressions, the heart beat at the apex, outside position of the larynx is indicated by the trachea at the suprasternal notch to see

Trachea

Upper Lobe Bronchus RT. Upper Lobe Bronchus LT. Main Bronchus Horizontal Fissure

Oblique Fissure Lower Lobe Bronchus

Lower Lobe Oblique Fissure Bronchiole

Fig. 25 : The bronchial tree

65 if this is deviated to one side (pulled or suprasternal notch, the sound is normally pushed by underlying disease), crepitations, 'tubular' It is high pitched and loud. i.e. crackling sounds, for subcutaneous 'Vesicular' breathing is heard all over the emphysema (where air leaks from the lungs lungs except over the upper middle sternum into the subcutaneous layer of the skin.) and at the upper mid-back between the Percussion: This is done by putting scapulae. This sound is high pitched and one hand flat on the chest with fingers loud during inspiration and low pitched and separated and the middle finger tapped by softer in the expiration. 'Bronchovesicular' fingers of the other hand. This is done breathing is heard over the main bronchi, systematically above downwards and the i.e. below the clavicles in front and scapular two sides are compared. Diminished sounds region at the back. This is medium in pitch (referred to as dullness or impaired sounds) and intensity both in inspiration and of the underlying lung indicate that the area expiration. The duration during inspiration of the lung is either not filled with air and expiration of different breath sounds is (collapsed) or is solidified (consolidation of diagrammatically explained below: pneumonia) or there is fluid underneath To begin with, breathing sounds are (pleural effusion). Increased sound heard all over and any diminution or (tympanitic note) is heard if the lung is increase in pitch, intensity of sounds and overfilled with air (emphysema) or there is quality, other than expected for that air in the pleural space (pneumothorax). In anatomic area, is noted and compared on an infant and toddler percussion can be the two sides. Look for the following: done in the sitting or standing position and in lying position in older cooperative l Decrease in breath sounds: children. Pneumonia, pleural effusion, emphysema, pneumothorax Auscultation: The choice of chest l piece of stethoscope for children is the one Tubular/ bronchial breathing is normal with diaphragm because the chest sounds in over trachea but if present over lung children are of high frequency. Again, as for parenchyma, it indicates consolidation palpation and percussion, an infant and or collapse (atelectasis) toddler can be examined sitting or even l Reduced or absent breath sounds over standing. To be able to hear sounds well the an area indicate a solid mass, air or child is asked to breathe deeply. While older fluid in the pleural space. children can do that, younger children can l Bronchophony: If the sound normally be asked to blow as they would, a balloon heard over a bronchus is heard over or a candle. Often, if the examiner asks the another area it indicates that the child to imitate the examiner, as she breathes deeply in and out, children oblige as they are good at imitation. A smaller infant cannot be made to breathe deeply. The object of auscultation is to hear the breath sounds and any abnormalities of these sounds that occur in disease states. The examiner must first be able to recognize normal breathing. Over the trachea at the

66 underlying lung tissue is solidified aortic, left and right atria, the two ventricles (pneumonia etc) so that the breath and the apex must be recorded in memory sound is as clear as that heard over a to be able to detect what is abnormal. Pulse normal bronchus and blood pressure are recorded first. (See l Egophony: nasal, bleating sound vital signs under general examinatioin heard over an area of pneumonia above). We then proceed with the inspection, palpation, percussion and l Whispering pectoriloquy is whisper auscultation of the heart. sounds heard as if spoken directly over the chest piece of the stethoscope. If Inspection: Look for any bulging in heard over the upper iterscapular the heart area. In heart enlargement a bulge region, it is usually due to mediastinal is seen on the left side, particularly if the lymph node easily conducting sounds chest is thin. In such a case the apex beat is to the chest due to their solid visible as a pulsation. Any engorgement of character. veins in the neck should be noted in an older child but in an infant there hardly is Any abnormal (adventitious) sounds any neck so that neck veins are not visible. are looked for. Following sounds are heard Chest deformity may be associated with in various conditions: congenital heart disease. l Crepitations are crackling/bubbling Palpation: Palpating with the fingers, sounds in air passages, and are due to first the apex beat should be identified by breaking of bubbles of secretions in the air passages. Fine crepitations feeling the fifth intercostals space at the left occur because of snapping open of midclavicular line. Its features are noted, collapsed alveoli. such as location beyond midclavicular line, indicating enlargement. Apex beat is absent l Rhonchi are 'snoring' sounds produced on the left but felt on the right side in by air passing through passages dextrocardia. It is also displaced in narrowed because of swelling of the congenital heart disease. Any thrill, which is lining mucous membrane of these indeed a palpable murmur, is noticed in passages and secretions. respect of location, intensity and timing l Pleural rub (friction rub) occurs when (systolic or diastolic). The suprasternal there are secretions in the pleural notch is palpated to see if the trachea is space resulting in a crackling sound median or deviated to one side. Deviation when the two layers of the pleura rub means that the mediastinum is pushed or against each other during respiratory pulled to one side as happens in lung and movements. heart disease for example a large pleural 2. Cardiovascular System: effusion, emphysema, atelectasis (collapse) Chest examination includes respiratory or in an enlarged heart etc. system and examination of the heart. Percussion: In smaller infants, in Examination of the heart includes view of the thick fatty layers of the chest Inspection, Palpation, Percussion and and its barrel shape, percussion is difficult. Auscultation like the respiratory system. We Percussion is done to identify heart borders must first appreciate the location of the to note if there is enlargement. Percussing in heart in the chest. The location of pulmonic, the fourth and fifth space from the left side

67 inwards towards the heart indicates Variations occur between heart rate enlargement if the cardiac dullness is and rising temperature (roughly an beyond (more to left) of the apex. The increase of 10 beats per degree rise of normal right heart border can be felt on Fahrenheit temperature). Heart rate percussion and is just to the right of the and pulse rate should be same but any right sternal line at the level of the fourth difference is called pulse deficit. If rib. If the left second interspace is dull, it there is a difference in the rate of could indicate enlargement of the left radial and femoral pulse it is indicative atrium. Normally this space is resonant. of 'coarctation of the aorta' l Auscultation: This is carried out Rhythm: Normally the interval conventionally in four important areas viz, between heart beats is equal but in aortic, pulmonary, tricuspid and mitral. For children 'sinus arrhythmia' may be a good examination of the apex of the observed in which the rate is higher heart, auscultation is done with the child during inspiration than during lying on the left side. For pulmonary and expiration. Abnormalities of rhythm aortic areas, auscultation is best done with are 'regular', i.e. arrhythmia is child in sitting position, bending forward. In "regularly irregular", following a each of these four areas, both first (S1) and pattern of irregularity. Sinus second heart sound (S2) are heard. To arrhythmia is an example. If it is decide which is the first and which is the "irregularly irregular", i.e. it follows no second sound, palpate the carotids in the pattern of irregularity, examples are neck while you are auscultating- the carotid auricular and ventricular fibrillation. beat determines the first sound. First heart These are clearly seen on an EKG sound is due to closure of the two record. A 'gallop' or 'triple' rhythm is a atrioventricular valves (mitral and tricuspid) serious finding necessitating urgent and opening of the two semi lunar valves, attention. This occurs in myocarditis. l (aortic and pulmonary), due to increase in Intensity of sound: S1 is more pressure during contraction. The second intense than S2 at the apex. The heart sound results from closure of the reverse is true of the base of the heart pulmonary and aortic valves. The left where S2 is more intense than S1. ventricle closes just before the right so that l Quality of sound: If it is not clear the aortic valves close earlier than the and is muffled, diffuse or indistinct, it pulmonary resulting in a normal 'splitting' of needs to be investigated. the second heart sound in children. This is best heard over the upper left sternal edge. Other than normal heart sounds The split widens during inspiration and adventitious sounds or murmurs are heard narrows in expiration. Variations in this by auscultation carefully. Sounds are splitting are clinically significant. produced in the heart or large vessels as a result of flow of blood to and fro in Evaluation of heart sounds is done in abnormal situations. These are timed with respect of rate, rhythm, intensity and the first and second heart sounds and are quality: accordingly termed as 'systolic' or 'diastolic' l Rate: (See pulse under vital signs murmurs. Some murmurs are benign and of above). The range of normal heart no pathological significance. These are rate is given in table on p. 61. called 'functional murmurs'

68 Murmurs are observed and recorded as under: l In terms of intensity or loudness and are classified on a 4-popint or a 6-point scale as grade 1 to VI or grade l to IV. 1 3 l Timing in relation to first and second heart sounds. l Site where best heard. l Quality, like blowing, rumbling, harsh, musical etc. 9 l Pitch: High pitched or low pitched. In addition to murmurs a pericardial friction rub can be heard as an abnormal sound. This is a grating or crackling, harsh sound heard at the apex due to rubbing of the outer and inner layers of the pericardium due to inflammation within the Fig. 26 : Demarcation of quadrants of the abdomen pericardium. This disappears when the fluid for recording findings of inspection and palpation etc. inside increases by separating the two layers (1) right hypochondriac (2) epigastic that produce the sound. (3) left hypochondriac (4) right lumbar (5) umbilical (6) left lumbar (7) right iliac 3. Abdominal examination: (8) hypo gastric and (9) left iliac. Inspection: A note is first made of gently, while pleasantly talking to the child the general appearance of the abdomen. An and distracting his attention. Crying makes infant normally has a rounded 'pot' belly the abdomen taut and difficult to feel the unlike an older child, an adolescent or an contents, so if the child is breast fed while adult who has no obvious fullness. This is he is palpated in mother's lap or given a because of the greater subcutaneous fat pacifier, it may ease palpation by preventing content at this age. The abdomen is divided crying. Look for any mass, tenderness, into quadrants (see Fig. 26) and any rigidity in each quadrant and any fullness, mass etc should be described. Note visceromegaly, i.e., liver, spleen, renal mass the umbilicus for any swelling, discharge, etc. Liver is normally palpable about 2 cm. hernia, polyp etc. Look for any venous below the costal margin in infants. It is engorgement on the abdominal skin. The considered abnormal if it is tender, firm or abdomen may be distended from fluid hard, or if a sharp liver edge is felt. Its inside (ascites), gas, or a mass related to enlargement is recorded in cms below the viscera. Peristaltic waves may be noticed as costal margin in the midclavicular line. a result of obstruction of the intestinal Spleen is not palpable normally, but if it is, lumen, e.g. in pyloric stenosis. it means it is enlarged two to several times. Palpation: In an infant, this can be As required palpation can be done in left carried out in the mother's lap and in an and right lateral positions for the spleen and older preschool child, in the standing liver respectively. For the kidney, palpation position. The examiner's hand must be should additionally be carried out in the warm and palpation should be carried out flanks also in view of it deeper position in 69 the abdomen. The full bladder may l Higher function: sometimes be palpable in the suprapubic State of consciousness, alertness region. It is normal if the swelling disappears after the child passes urine. Ascites is Development (behavioral) (See table determined by palpating the fluid thrill thus: on page 24-26 The Normal child) while the child lies flat on his back, a l Cranial nerves (I-XII) colleague places the edge of her I. Olfactory: Smell outstretched hand in the middle of the II. Optic: acuity of vision, field of abdomen; the examiner taps the abdomen vision, color vision fundus. in one flank and feels the wave with the other hand placed on the opposite flank. III. Oculomotor, IV Trochlear and VI Fluid in the abdomen can also be Abducent: Eyeball movements demonstrated by carrying out 'shifting V. Trigeminal: Sensory: Three divisions dullness (see percussion below). Palpation (ophthalmic, maxillary and mandibular of the abdomen is incomplete without responsible for sensations in the three palpating the hernial sites and a rectal areas Motor: muscles of mastication examination. The genitals should be VII. Facial nerve: Motor nerve palpated for hernia, hydrocele, cysts or any movements of muscles of and scalp visible or palpable abnormality. and face Percussion: As for palpation, a VIII. Auditory Nerve: Hearing careful examination is done, quadrant wise, by percussing for any masses, organs, fluid IX. Glossopharyngial: Taste sensation etc. 'Shifting dullness' is elicited thus: the of posterior third of the tongue and child lies on its back, percussion is carried pharyngeal mucous membrane. Motor out from the umbilicus towards one flank nerve for some pharyngeal muscles which is dull because of the fluid present. X. Vagus: Motor nerve for soft palate, From this position the child is turned to the pharynx and larynx sensory and motor other side. After waiting for a moment, to let for the respiratory passages heart and the fluid flow to the other flank, percussion abdominal viscera. is done again. If the note is now resonant it XI. Acccessory: Motor for indicates that fluid is present and has shifted sternomastoid, trapezius muscles. to the other flank. XII. Hypoglossal: Motor nerve: Auscultation: For silent abdomen in Movement of tongue acute intestinal obstruction, borborygmi, l systolic bruit etc. Motor System: Testing is done for: v Rectal examination & inspection of Posture and attitude hernial sites and genitals is an important v Muscle tone part of examination. v Muscle nutrition 4. Central Nervous System v Coordination examination: v Muscle power A brief summary of examination of the v Abnormal movements. CNS is as under. For details of technique l refer to books describing clinical methods in Sensory functions: children v Touch sense 70 v Temperature sense the nature of the lesion (inflammatory, v Pain sensation neoplastic, degenerative, or congenital)? v Knowledge of anatomy of the nervous Joint sense (position) system and an intellectual clinical approach v Vibration sense (with a tuning determine answers to these questions. fork) Certain reflexes and signs such as l Reflexes: 'Moro's', 'Grasp', 'Rooting'' etc. and v Superficial: Plantar and development assessment described on p. 27 in abdominal reflexes Superficial section I- ('the normal child') determine reflexes related to cranial nerves: maturity of the nervous system. The important Conjunctival, papillary, corneal reflexes and signs that appear during the first and palatal year are shown in the table below: v Deep: Tendon reflexes: ankle, Late appearance or absence of these knee, biceps, triceps, wrists reflexes or their persistence beyond the expected time limit indicate brain damage v Organic reflexes: Functions of and call for investigations for nature of swallowing, micturition and damage and management. defecation It can be carried out with the help of l Gait: Child is observed during walking. the knowledge of the CNS and the clinical l Special clinical tests as required. findings, for example: if a child's intellectual Examination of the nervous system in development is impaired, consciousness is an infant and small child differs from that of altered (coma etc), or convulsions occur, the the adult in that the infant's CNS is in a lesion is in the brain. If intellectual stage of maturation. So the first question is: development is normal but he has delayed has the system matured appropriate for the motor milestones, the lesion is in the child's age? The next question is: is there a anterior horn cells of the spinal cord (in focal lesion? The third question: where in infantile spinal muscular atrophy). Weakness the nervous system is the lesion located, i.e. of lower limbs may result from a lesion in site of lesion (localization)? Lastly: what is the spinal cord or in the cerebral

Reflex How to elicit Appears Disappears at at

Moro It is the 'startle' response or 'embrace' response Birth 4-5 mths Hold baby supine over Rt. arm with head on palm, Drop palm by 30°, rapid abduction & extension of arms and 'embrace' movement of arms occurs Grasp- palmar Place your fingers on baby's palm or sole, grasp or Birth 3-4 mths and plantar flexion of digits occurs TNR Tonic Neck Reflex: Gently turn baby's head to one 2-3 wks 4-6 mths side, opposite side leg and arm extend and same side flex. Rooting, sucking Stimulate angle of baby's mouth with finger, the Birth 3-4 mths baby tries to mouth and suck the finger. when awake

71 hemisphere. A 'foot drop' may indicate (See Fig. 27) with the baby's legs pressed peripheral nerve, spinal cord or hemisphere between her legs so that the baby cannot lesion. In peripheral nerve disease tendon move its legs. With one arm the mother reflexes are diminished, in spinal cord holds baby's both arms across the chest and disease jerks are increased and in with the other hand steadies the baby's hemisphere disease there are increased deep head, pressing it against her chest firmly, jerks, cortical sensory loss and mental enabling the doctor to examine the throat changes. Ataxia is usually due to cerebellar with a tongue depressor. The mother can disease but it may be a false localizing sign then turn the baby's head to the side, since ataxia also occurs in the involvement holding it against her chest with baby's one of the connections of the cerebellum. ear facing the examiner, allowing examination of the ears, one after the other. Restraining techniques during If required to be examined lying on bed or examination examination table, the mother or another Infants and young children need to be restrained while carrying out certain examination or nursing procedures because they resent these and often struggle and cry during these procedures. Techniques in doing so have to be gentle but effective to enable the procedure to be carried out properly, preventing injury to him. The selection of the restraining technique depends on what is required to be done, age of the child and the part/ parts required to be restrained. Restraining is required in the case of Fig. 27 : Restrainimg child for ear examination an infant and young child during examination of the throat, ears, and nose, colleague holds both arms of the baby along and rectal examination. These can be done the side of the head pressing them firmly on with the help of the parent, preferentially the the sides. This allows examination to be mother, or a nursing colleague. If none are conducted without letting the baby's head available a restraining sheet is first wrapped move. If there is no help and the worker has round one arm (say left), then round the to examine the throat alone, a sheet of chest and outside the other (say right) arm cloth, broad enough to be wrapped twice and finally round and over the left arm and round the child from shoulder to the hips, chest. Such a procedure restrains the arms, can restrain the arms. leaving free the head and lower limbs Rectal examination: The baby is enabling examination and procedures to be made to lie on one side, say right side, with carried out such as mouth ears, neck, and leg of same side (right leg) straight and the legs. other (left leg) flexed over the abdomen. Examination of the ear nose and This exposes the baby's anal region for throat: This can be done in the mother's lap necessary examination. A colleague holds or in the lying position on the examination the child in this position to enable the couch. The mother holds the baby in her lap examination. 72 SECTION 2 GENERAL PEDIATRICS

1. NUTRITIONAL DISORDERS: Protein-calorie Malnutrition 74 Vitamin Deficiencies 76 Mineral Deficiencies: Iron, Calcium & Iodine 78 2. INFECTIOUS DISEASES VACCINE PREVENTABLE Measles 81 Whooping cough 81 Diphtheria 82 Mumps 83 Rubella 83 Chicken pox 83 Poliomyelitis 83 Typhoid 84 Tetanus 85 Rabies 85 Tuberculosis 86 OTHER COMMON INFECTIONS Acute Rheumatic Fever 89 Malaria 91 Leishmaniasis (Kala azar) 92 Herpes Simplex 93 Infectious Mononucleosis 94 Cytomegalovirus 94 Dengue 95 Human Immunodeficiency Virus (HIV) 96 Toxoplasmosis 98 Leprosy 98 3. BEHAVIOR DISORDERS IN CHILDREN Parental attitudes in behavior disorders 101 Common behavior disorders 102 4. BASIC GENETICS Chromosomal abnormalities 109 Gene defects 109 Patterns of inheritance and common disorders 110 Common Chromosomal disorders 115 5. DOMESTIC ACCIDENTS 117 POISONING 118 BURNS 120 1 Nutritional Disorders

Disorders of nutrition arise largely Kwashiorkor from insufficient intake, either due to limited Causes: It results mainly from or no knowledge among parents, of the deficiency of protein although some calorie nature and quantity of food required by a deficiency also occurs with it. Lack of child or from conditions or illnesses protein causes edema. Since protein is also interfering with intake of proper foods. required in the synthesis of hemoglobin, Poverty is usually the common denominator. anemia also occurs in these children. The disorders may be grouped as under: Breastfed babies do not get kwashiorkor and 1. Protein energy or protein calorie therefore it occurs usually after the first year malnutrition, termed PEM or PCM for when breast feeding is almost over and top short. Lack of protein and calories food introduced lacks in protein. It is a result in either of two types of clinical common sight in rural areas where a picture: Kwashiorkor or marasmus. breastfed baby in the mother's arms is 2. Vitamin deficiencies as a result of lack plump while his older sibling walking along of intake of foods containing these, with the mother is thin and wasted. The diet including vitamin A, D, E, K, C, and of children with kwashiorkor is mainly the B complex factors carbohydrate since poor parents cannot 3. Minerals, like Iron deficiency causing afford protein foods like milk, cheese, eggs anemia, Iodine deficiency resulting in and animal foods as they are expensive. Or goiter, and others including calcium, parents do not have the necessary magnesium and some trace elements. knowledge about feeding requirements. Causative factors linked to malnutrition are: 1. Protein-Energy or Protein- family poverty; food habits and traditional Calorie Malnutrition usage which diminish food intake or exclude (PCM or PEM): useful and available foods; large family size; The deficiency of proteins and calories illiteracy; care of younger children by older can cause kwashiorkor or marasmus. sibs while their mother's go to earn their living. Clinical features: The features of Kwashiorkor are: l Characteristic v Generalized edema, v apathy (sadness, lack of playfulness and smile), and v failure of growth (underweight) l Additionally v Skin and hair changes that consist of peeling off, Fig. 28 : Kwashiorkor pigmentation, pavement like pattern of skin and light hair. and two dals are mixed, the total value of Kwashiorkor, meaning 'red head' their amino acid content is much more than in the African dialect, gets its their sum total. For normal requirements see name from the appearance of chapter on nutrition in section I (p 31, 32). hair which looks somewhat red. Severely malnourished children suffering Hair looses the pigment melanin from kwashiorkor may need to be and looks somewhat dull, brittle hospitalized and fed with a nasogastric tube and course while the mother is educated about what and how much to feed. (See section I on v Hepatomegaly is due to fatty nutritional requirements). Since these liver changes. children are prone to hypothermia, v Severe cases may develop hypoglycemia and even cardiac failure that hypothermia and often die of it. can prove fatal, they need warmth, and IV v Hypoglycemia fluids. Blood transfusion may be required in those who are anemic. v Cardiac failure Classical kwashiorkor is getting less Marasmus. frequent and is disappearing in communities Causes: Starvation diets (global or which have access to improving health pan-deficiency of both protein and services, economy and education. Milder carbohydrates) forms may present with milder edema and This term describes failure to grow as other signs. a result of insufficient food. Failure of Treatment: These children need lactation is an important cause of early protein in their diet and as said, proteins, marasmus as that is the only food in early especially animal proteins (milk, poultry, fish infancy. As stated above the factors and mutton) are expensive. Proteins are associated with malnutrition are: family made up of amino acids and animal poverty; food habits, large family size with proteins contain good quality of amino worst effect on the siblings born later, acids. Further, vegetarianism prevalent in illiteracy and therefore lack of knowledge of India excludes animal food (except for milk) foods, care of younger children by older sibs from their diet. The main source of protein while their mother's go to earn their living is therefore from milk and vegetables etc. including peas, beans, lentils and staples like wheat etc. which are individually, not very Clinically these children appear thin rich sources of amino acids compared to and wasted. There is failure of weight gain, fleshy foods. Whereas animal proteins fulfill the head appears large as compared to the the needs in smaller amounts, vegetable wasted body, face appears like that of an proteins are required in larger amounts, old man with a pointed chin and hollow resulting in bulky diets. In view of the cheeks, muscles are thin and fat is lost so limited stomach capacity of infants and that the skin goes into folds, ribs and other toddlers, bulky diets need to be divided into bones are prominent because of the loss of smaller, frequent feeds to avoid fat but unlike kwashiorkor, there is no malnutrition. Mixed diets consisting of more edema. than one cereal or lentil improves the Treatment: This is not protein alone energy value of the feed several times. For but total quantity of all foods is lacking, example, if two or three dals or one cereal including protein and calories from all food 75 incidence is falling with prophylactic vitamin A given under various health programs. Sources: Milk, butter and other fats, green vegetables especially carrots and fruits Wasting growth like apple, bananas and papaya, failure 'Old Signs of deficiency: Change of man' looks loose skin luster of conjunctiva and conjunctival folds at the outer canthus- called xerosis. There is pigmentation at the conjunctival gutter. Bitot's spots are white raised spots lateral to the scleroconjunctival junction at 3 o'clock (left) and 9o'clock (right) positions. Night blindness is present. In the event of corneal involvement, the child avoids light (photophobia). Corneal changes follow those in the conjunctiva. At first the cornea Fig. 29 : Marasums looks dull and later becomes soft (Keratomalacia). Perforation and infection sources. Thus the treatment is more food- occur with scarring and destruction of the larger amounts of food. As said the energy cornea. value of foods from vegetable sources is lower and therefore a bulky diet is required. Prevention: Green leafy vegetables, Since the child cannot eat a big meal, carrots, and yellow fruits like mango, smaller and frequent feeding is necessary to papaya etc are good sources. Under the ensure sufficient proteins and calories. National Blindness Prevention program, Further, mixed diets containing several children 1 to 5 years are given 200,000 cereals and lentils provide more energy. units of vitamin A every 6 months at the Education of the mother or the care taker is PHC's. Feeding of Colostrum to breast fed absolutely necessary to ensure continued babies, rich in Vitamin A, postpones care and prevention of relapses. As a long development of vitamin A deficiency. term policy, girls at school should be given Treatment: children with xerosis, lessons on food and nutrition including night blindness and Bitot's spots should be cooking methods since they are required to given 200.000 units of vitamin A in oil, look after their younger brothers and sisters daily for 4 days. Those with Keratomalacia: in large families. Also because they are 100.000 units of water soluble vitamin A by future mothers. IM injection followed by 100,000 units of 2. Vitamin deficiencies: the vitamin in oil orally for 4 days. (Children less than 5 kg get 50,000 units parenterally) Vitamin A: During diarrhea: 100.000 units aqueous This deficiency has been one of the solution alternate days. In bad cases of most common causes of blindness in India, corneal damage, an ophthalmologist should together with trachoma. No age is exempt be consulted. To prevent development of from its effect. Measles and tuberculosis anterior synechia, atropine should be used significantly contribute to its incidence. The locally to dilate the pupil and antibiotics 76 parenterally. The eye should be carefully subperiosteal hematomas. As a result handled to avoid perforation of an already movement of limbs causes pain so that a softened cornea. child cannot walk. X-ray appearance in scurvy : The B complex vitamins: For normal long bone structure see This group contains: Thiamine Fig. 30. (B1), Riboflavin (B2), Niacin, Pyridoxin l (B6), Folic acid, Cyanocobalamin, Biotin, Thins corex, sharply outlined epiphysis Pantothenic acid, Paraminobenzoic acid, ('ring epiphysis') Inositol and choline. They act as coenzymes l Ground glass appearance of bones in cells. Treatment is with the appropriate with loss of trabeculation. vitamin 1 to 10 mg daily for all except Folic l Fraenkel's white line : thick, irregular acid which is 0.5 mg to 1 mg and B12 white line at the epiphysis. which is 1 mcg daily. (See table below for l Spurring : Lateral extension of the details) same line beyond the epiphyseal Vitamin C: (Scurvy) margin. l Sources: Milk, green vegetables, Zone of rarefaction proximal and fruits especially citrus fruits. The vitamin is parallel to the white line. destroyed if vegetables are boiled or l Subperiosteal hematoma separating cooked, so fruits should be taken such as periosteum from the bone gets oranges and lime. calcified and gives a characteristic Clinical signs of deficiency: appearance. Scurvy: bleeding, soft gums, bruising of Treatment: Vitamin C orally in the skin, bone tenderness resulting from form of ascorbic acid daily for one month.

Name Cause Features Treatment Thiamin (B1) Deficient pregnant Heart failure, edema, Thiamin inj. 50 mg stat and mother; polished neuropathy (tingling, 10 mg daily orally for two rice diet numbness, weeks. Pulses, vege-tables in diminished jerks) diet. Riboflavin (B2) Dietary deficiency Glossitis, cheilosis, Cereals, sprouted pulses, redness of eyes, scaly vegetables, Liver, kidney, yeast, dermatitis, pruritus, eggs, nuts Riboflavin 1- 10 mg seborrhea daily Niacin Populations using Pellagra- causes 3 D's: Same as above maize as staple diet diarrhea, dementia, dermatitis Pyridoxin (B6) Isonizid administration Convulsions, Same as above to pregnant mother polyneuritis Folic acid Folic acid deficiency Megaloblastic anemia, Same as above diarrhea 0.5 to 1 mg daily Cyanocobalamin Megaloblastic anemia, Same as above Vitamin B 12.1 (B12) CNS changes microgram daily

77 Vitamin D: (Rickets) l The broadened costochondral Sources: Sunlight acting on skin, and junctions at the ribs give the certain foods. Being fat soluble like vitamin characteristic clinical finding of A, E and K, it is found in butter, oils, milk beading ('rachitic rosary'). and milk products, eggs, fish and liver. Rickets other than that resulting from Signs of deficiency: Deficiency Vitamin D deficiency occurs from Renal Rickets, (different from metabolic and renal disease (renal rickets) and metabolic disease rickets). Deficiency rickets occurs at age (metabolic rickets from disturbances of when growth is most rapid, i.e. below three amino acid, calcium or phosphorus years. The signs of deficiency are: metabolism) l Enlargement of epiphysis of ribs at Treatment: 2000-5000 i.m./day for their junction with the costal cartilage, 6-12 weeks. and at wrists and ankles. The bead like Vitamin E deficiency: appearance of the enlarged costochondral junctions along both Sources: Present in most foods. A fat sides of the chest is often called the soluble compound, Tocopherol, is the most rachitic 'rosary' The soft ribs bend to important source of vitamin E and each mg form a depression called the of it provides 1.5 IU activity of vitamin E. 'Harrison's sulcus' Signs of deficiency: Rare. l Bending (bowing) of bones from loss Neurological signs are poor reflexes, of rigidity as a result of posture. The unsteadiness, and weakness of muscles and tibia is bowed outwards at the lower in some premature infants may result in third if the child is walking hemolytic anemia. l The skull bones in young infants are Treatment: 3 mg daily of a- soft so that pressure with the thumb tocopherol. gives rise to a sensation of Vitamin K deficiency: 'Craniotabes' like the sensation a ping pong ball gives on pressure. Sources: Absorbed from food in the gut where it is synthesized by intestinal l Soft flabby and weak muscles bacteria Vitamin K is required for production l Some infants may demonstrate signs of normal blood clotting of Tetany in the form of muscle Signs of deficiency: Seen only in irritability associated with calcium newborns, in chronic liver disease or deficiency. steatorrhea. X-ray appearance in rickets Treatment for the newborn: See l Best visualized at wrists : Course chapter on the new born (p. 139). trabeculation of diaphysis and general rarefaction of bone. 3. Mineral deficiencies: l The sharpness at the distal end of the There are many minerals and trace metaphysis is lost and replaced with elements whose deficiency can occur but frayed margin. those clinically significant in terms of their l The metaphysis is widened at the deficiency in food are Iron, Calcium, distal end Magnesium and Iodine. The requirements of

78 these is discussed in section 1 in the chapter fatigue. Prolonged anemia may 'Nutrition and Nutritional requirements' present as edema, cardiac enlargement (table on pages 30 & 31) and even failure. Anemic children are l Iron deficiency: Causes In the susceptible to repeated infections. newborn, deficient iron stores can Since anemia can result from other occur from prematurity or from fetal causes, such as hemolysis, bone blood loss (see chapter on 'The marrow depression and other Newborn" under anemia in the deficiencies (see chapter 3, under newborn). If the baby is weaned late 'Pallor'), iron deficiency needs to be and the diet is exclusively milk, anemia confirmed from blood counts, from lack of iron in the solid feeds can hemoglobin, red cell count and lab cause iron deficiency. Blood loss from tests for Iron estimation). any cause- hidden (as from the gut Treatment would depend on severity. If etc) or manifest, can result in anemia hemoglobin is very low, blood as also intestinal disease, diarrheal transfusion may be required. If less disorders and malabsorption. severe, parenteral iron can be given Clinically, anemia presents as pallor of but this is not common practice in skin, nails and the mucosa (tongue, children. Oral therapy with iron and oral), lethargy, weakness and easy increased iron in the diet can be effective in milder anemia. Foods rich in iron are dry fruits especially dates; Articular pulses; leafy vegetables particularly Cartilage spinach and egg plant; non vegetarian families can be prescribed `egg yolk, Cancellous Bone (Contains Red Marrow) liver and kidney. Oral iron therapy depends on age and severity of Epiphyseal Plate anemia. (Table p. 32) Metaphysis l Calcium deficiency: This deficiency purely from dietetic deficiency is unusual and may be associated with Medullary Cavity rickets. Tetany is a manifestation of hypocalcemia when serum calcium Diaphysis level is less than 2.5 mg/dl. (Normal 9.5 to 11 mg/dl). Periosteum Causes of its deficiency are: In the neonatal period and infancy: IU Growth retardation, prematurity, babies born of diabetic mothers, prolonged difficult delivery, high phosphate load from feeding of cow's or other phosphate rich formulae Epiphysis (which is associated with low serum calcium). Other causes are parathyroid disease (hypoparathyroidism). Fig. 30 : Long bone (Longitudinal Section)

79 Clinically, tetany can be manifest or l Iodine deficiency: The largest latent (hidden). Manifest tetany number of people in the world, presents as carpopedal and laryngeal suffering from iodine deficiency as a spasms. Carpopedal spasms consist of result of shortage of this mineral in the flexion of wrists with extended fingers water, live in the Himalayan belt and abducted thumb. Laryngospasms extending from Kashmir to Nagaland. result in crowing breathing and croup However the rest of India is not from inspiratory obstruction as a result entirely free of this deficiency. The of vocal cord spasm. Latent (hidden) deficiency causes goiter of various tetany can be brought out by grades, hypothyroidism, varying procedures called the Trousseau sign degrees of mental retardation, hearing and chvostek sign. Trousseau's sign is and speech defects, eye changes like elicited by applying a BP cuff to the squinting and nystagmus, spasticity upper arm and maintaining pressure and neuromuscular weakness. In above systolic, for three minutes-this pregnant mothers the deficiency can results in carpopedal spasms. cause fetal deaths and abortion. Chwostek's sign is elicited by tapping Certain "goitrogenous" chemicals the peroneal nerve over the head of (present in water or foods including the fibula which results in dorsiflexion cabbage and cauliflower) can interfere and abduction of the foot. Convulsions with iodine utilization by the thyroid can occur from hypocalcemia. gland and result in goiter. Large scale Treatment depends on the cause. prevention of iodine deficiency When clinical manifestations occur, a diseases is possible through use of 10% solution of calcium gluconate is 'iodized salt' in food. Certain national given IV at the rate of 2 ml /kg slowly, health programs are devoted to the monitoring heart rate (for control of this deficiency (Section 1, bradycardia). (Also see table on p. 31) Chapter 5 p. 46).

80 Some Common Infectious 2 Diseases of Childhood

Children are prone to certain infectious Treatment consists of supportive and diseases as a result of their immature nursing care including nutritional care, immune system. The immunity received hygiene of eyes, antibiotics only in case of from the mother through the placenta during pneumonia or otitis media. Preventive: fetal life and then through her milk (see p 32) Measles vaccine. lasts for a while and then wanes before the Whooping cough: Caused by child later develops its own immunity. This bacterial infection from Bordetella pertussis. period between waning immunity from Incubation period is 3 to 4 weeks. Most mother and development of own immunity infections occur during first few weeks. in later childhood leaves a gap and it is in Clinically earliest signs are nasal this period that most of the specific discharge and cough. The cough worsens infections of childhood occur. Vaccinating and becomes paroxysmal i.e occurs in procedures bridge this gap (see p 30) and severe bouts of prolonged cough during protect children from such 'vaccine which the child gets breathless and the face preventable diseases'. For immunizing turns red. At the end of the bout of cough a schedule see p 41). Some of the common long inspiratory whoop occurs which gives it infectious diseases are briefly described here. the name of 'whooping cough'. The bout of I. VACCINE PREVENTABLE cough ends up with vomiting. Paroxysms of cough are more frequent during the night. DISEASES The secretions are very thick and mucoid Measles: It is caused by a virus. The which can sometimes cause fatal obstruction incubation period is 10 to 14 days. Usually of the bronchus. The spasms of cough are occurs in children before age of 7 years. It is brought on by running, laughing or highly infective during the onset. excitement. Between attacks the child Clinically, starts with a cough in the appears well. The cough gradually subsides first week, nasal discharge and congestion of in 4 to 8 weeks but can take 12 or more the conjunctiva and pharynx.. Koplik's spots weeks. Recurrence is common. Pertussis can (salt rash) appear on inner surface of cheeks. occur at any age from newborn to adult. This is pathognomonic (characteristic and The incidence has fallen with DPT unique) of measles. In the next 3 to 4 days a vaccination but epidemics do occur rash appears behind the ears spreading on to periodically in a few years. face, body and limbs. This rash lasts 48 to 72 Complications include weight loss, hours and disappears in the same order that pneumonia, subconjunctival hemorrhage, it appears. Keratomalacia, interstitial or subcutaneous Complications include virus emphysema over neck and chest, pneumonia, otitis media, and encephalitis. If pneumothorax, prolapse rectum. These a child is malnourished, he may develop occur as a result of strenuous cough resulting Keratomalacia and kwashiorkor. If suffering in pressure during the coughing bouts. As a from primary tuberculosis, it may flare into residue of segmental lung collapse meningitis or miliary tuberculosis which can bronchiectasis may result in a few weeks or be fatal. months. Treatment is with antibiotics like death or onset of heart failure during the clarithromycin provided it is given within second to sixth week of infection, with liver the first two weeks of illness. Good sleep at enlargement and pulmonary congestion. night is essential and can be ensured with a Neurological complications include i) palatal dose of dextromethorphan or codeine syrup paralysis (around the 3rd week) with nasal before going to bed. Supportive treatment voice, nasal regurgitation and nasal twang to includes nutritional and nursing care. the voice ii) paralysis of accommodation Diphtheria: The causative organism occasionally with squint (3rd to 5th week) iii) is Corynebacterium diphtheriae and the paralysis of respiratory muscles, diaphragm incubation period is 1 to 6 days. Period of and pharynx (6th to 7th week) iv) Paralysis infectivity is 14 to 28 days. It spreads by of limbs (6th to 7th week). All these droplet infection from the patient or carrier. complications recover without any residue if Common age of infection is below 5 years diagnosis is early and treatment prompt. but it quite often occurs in school Diphtheria needs to be differentiated from epidemics. acute streptococcal tonsillitis, Vincent's Clinically it presents as laryngeal, angina of mouth and throat, infective faucial, nasal or cutaneous membrane. mononucleosis and oral thrush. Laryngeal diphtheria results in toxemia, Treatment aims at: a) neutralizing the hoarse voice, stridor or respiratory distress. exotoxin liberated by the organisms in the The faucial type presents as toxemia, sore throat into the blood; b) antibiotics throat, grayish white membrane which (penicillin or erythromycin) to clear the spreads over to tonsils and uvula, causes organisms from the throat to prevent enlarged cervical lymph nodes causing "bull liberation of further toxins and c) neck" appearance. Nasal diphtheria, apart management of laryngeal or tracheal from the toxemia, presents with blood obstruction with intubation, tracheotomy stained nasal discharge with pus. The and ventilatory care as required. Rest and cutaneous form appears as punched out careful nursing are required especially for ulcers with a thick margin and membrane at complications viz. myocarditis and cardiac the base. A very early diagnosis is essential failure. In the event of a school outbreak of to save life since diphtheria is often quickly diphtheria, which is most unusual now, in fatal. Diagnosis is confirmed from the throat the era of immunization, the school needs to swab for smear and culture examination. be closed for at least two weeks and a Complications include cardiac and protocol as follows carried out: Subject all neurological. Among cardiac complications contacts to throat swab smear and culture are myocarditis, arrhythmias, with sudden and Schick test and take action as under:

Schick test Throat swab Interpretation & Action Negative Negative Child is normal. No action Positive Negative Susceptible and uninfected. Carry out active immunization promptly Negative Positive Immune carrier. Erythromycin x 2 wks Positive Positive Susceptible & carrier. Erythromycin & Antitoxin 2000 units Test not possible: Positive Treat all previously unimmunized contacts with 1000 units antitoxin and Erythromycin

82 Mumps Cause: mumps virus. has had rubella in the past. Girls at puberty Incubation period: 14 to 28 days. Common should be given rubella vaccine to protect at age 5 to 15 years and can occur in adults. against infection to the fetus later during Infectivity: 6 days before to 12 days after pregnancy. beginning of symptoms. Chicken pox (Varicella): Infecting Clinically begins with fever and pain organism is a virus. Incubation period is 11 below and in front of the ear on one side to 21 days. and later to the other as well. This is from Clinically onset is with fever, swelling of the parotid gland which is headache, muscle pain, backache. The rash tender. Opening of mouth causes pain and first appears on the body, face and mucous stiffness especially during eating. The membranes. Pink spots turn into thin walled opening of the parotid duct inside the blisters, superficially on the skin. Clear fluid mouth near the last molar tooth is red. The in these becomes purulent and ruptures in other salivary glands-submental and four or five days, forming a scab later. Rash submandibular may also enlarge. The appears in crops and in different stages at swelling settles in about 5 to 10 days. the same time i.e. a macule, papule and Complications: Mumps encephalitis pustule may all be present at the same time. and orchitis. Prevention: Mumps vaccine. There is itching and scabs separate after 1 to (See immunization schedule). 2 weeks. Scratching may leave some Treatment: None specific. Oral hygiene depressed scars. with antiseptic gargles Complications include encephalitis Rubella (German measles): specifically cerebellar involvement. Causative organism is a virus. Incubation Prognosis in most cases is good. period: 14- 21 days. Treatment is non specific. Itching can Clinically: Mild disturbance, slight be relieved with lotio calamine used locally headache, some neck stiffness, enlargement Acyclovir or vidarabine can be given to of occipital lymph nodes. There is no immuno-compromised children. coryza. A pink rash, smaller than measles, Poliomyelitis: Causative organism is spreads over face, body, arms and legs. The the Polio virus which has three serotypes- rash disappears in 48 hours. Types 1, 2 and 3. Epidemics are mostly from Complications are rare and include type 1. Like typhoid, dysentery and polyarthritis, bleeding and purpura from infective hepatitis, infection occurs from thrombocytopenia, pneumonitis and contaminated food and water. Infectivity is hepatitis. Rubella in children, though a mild mostly just before to about a week from the illness, it has devastating effect on the onset of symptoms. After staying a week in growing fetus in a pregnant mother exposed the mucosa of the throat, the virus is to rubella. If mother is affected in the first excreted in the stools for upto 8 weeks. The trimester, the fetus is severely affected and incubation period is 7 to 10 days. The can be born with cataracts, deafness maximum incidence is during the rainy congenital heart disease, brain damage and season and the peak just after monsoons. mental retardation. After the 12th week upto Clinically: the illness may present in the 20th week the risk is less. Rubella in the the form of initial illness with fever, sore first three months of pregnancy justifies throat, nausea, vomiting, loss of appetite termination of pregnancy unless the mother and loose motions. If no further illness 83 develops it is given the label of abortive (fixed days announced every year) in polio. The illness may after a brief period, addition to the routine immunization carried be followed by fever, sweating, irritability, out at health centers (See p. 41). head and neck stiffness, pain in the neck, Typhoid: Causative organism is back and limbs, If this illness settles down it Salmonella typhi bacillus belonging to the is labeled non paralytic polio. However, this salmonella group which can cause stage may rapidly develop into the Paralytic meningitis, osteomyelitis, gastroenteritis etc. stage most often in the limbs but may Typhoid fever results from water or food involve muscles elsewhere. Some children contaminated with S.Typhi. `Paratyphoid is may have in additional to the spinal caused by the subgroup of salmonella called involvement, encephalitic and bulbar forms S paratyphoid. In view of the contaminated (cranial nerves and medulla with paralysis food and water source, the condition is of respiratory muscles). Bulbar form is the more frequent in poorer, less literate, most dangerous and often fatal form of crowded communities living in unhygienic illness. The brain stem and medullary conditions. The illness is much less frequent involvement in this form takes a rapid in children below 5 years, to the extent of course, developing into drowsiness, 10 per cent of all cases compared to older respiratory depression, circulatory center children and adults who form the bulk. The involvement and collapse. The CSF may incubation period is 10 to 14 days. show mild lymphocytic cell increase during Infectivity: Infected patients excrete the the paralytic stage. bacilli in urine and stool for several weeks Management of Poliomyelitis, after the initial infection. Some children are particularly the paralytic and brain long term carriers. On oral ingestion the involvement calls for the following care: bacilli settle and multiply in the intestinal Complete bed rest, positioning of limbs in mucosa and enter the blood stream via the the 'maximum comfort' position, warm lymphatics.The bacilli, after a while, enter moist fomentations, avoidance of injections the liver, spleen, gallbladder and bone or exertion and symptomatic treatment. In marrow and multiply. They invade the the event of progression, watch for Peyer's patches of the intestines, cause respiratory and circulatory signs and inflammation resulting in perforation and anticipate need for ventilation and other hemorrhage. Fortunately both these measures for prompt and life saving action. complications are rare in children. As per present government instructions all Clinically the sequence is onset of patients presenting with a flaccid paralysis rising fever, coated tongue with free margins have to be notified for analyzing stool (strawberry tongue), distended tympanitic samples for isolation of polio virus. Under often painful abdomen, vomiting, gurgling, the polio eradication program, figures slight cough and mild hepatomegaly, and in indicate falling incidence of the disease but about a week palpable soft spleen. Fever unfortunately it has not yet been eradicated fluctuates by a degree or two but does not totally as required in the global program. touch normal. Right upper abdominal While most countries of the world are tenderness and pain may occur from gall declared 'polio free', cases are still being bladder inflammation (acalculus reported from some areas of UP Bihar and cholecystitis). Towards the last phase of other states in India despite extensive illness some children develop 'typhoid measures. Parents should be encouraged to encephalopathy' and meningism. The give OPV at every Pulse Polio campaign features that distinguish typhoid in children 84 from those in the adult are: a) rapid rise of hygienic instrument (blade or scissors) to cut fever unlike the 'step ladder' pattern in the umbilicus has considerably reduced the adults, b) there may not be disproportion incidence of tetanus in the newborn. In between pulse and temperature referred to older children and adults the disease occurs as relative bradycardia in adults c) intestinal from contaminated, usually roadside perforation and hemorrhage much less wounds, otitis media etc. frequent in children since in children Clinically the signs are inability to feed lymphoid intestinal patches are poorly and open the mouth (trismus), spasms of developed, d) CNS findings in the form of facial muscles giving a 'sardonic' smile (risus meningism and typhoid encephalopathy are sardonicus), general muscle spasm and common in children and unlikely to be seen stiffness, arching of back (opisthotonus), in adults, e) the fever may not always be marked abdominal wall stiffness (guarding) continuous in children. during spasms, spasms of respiratory and Diagnosis is made from clinical laryngeal muscles, cyanosis during spasms, suspicion, blood culture, Widal test after one fever. Coma may occur in some patients. week and repeated after 10 days to confirm Treatment is mainly directed at: a) rise in the titer of 'O' antigens. The eliminating bacilli from the wound with the diagnostic titer is 1/250. help of antibiotics, b) neutralizing the Management includes use of specific exotoxin circulating in blood with the help antibiotics, which in the past was of antitoxic serum or Tetanus immune chloramphenicol. Ampicillin, Amoxicillin globulin, c) relieving spasms with heavy and Cotrimaxazole have been effective. But sedation and d) nutrition provided with the in view of emergence of resistance to help of a nasogastric tube and intravenously multiple drugs, the choice of antibiotics has and good nursing care. Antibiotic: Penicillin become difficult. Ciprofloxacin is used with 200,000 units per kg body weight favorable results. Supportive management intravenously divided into four equal doses includes good nutrition with non or low for 10 days Human tetanus immune residue but attractive diet, fluids and globulin (TIG) 3000 to 6000 units stat and if symptomatic treatment. not available, ATS 50 thousand to 100 Tetanus: Causative organism is thousand units, half by IM route and half IV Clostridium tetany present normally in after a careful sensitivity test. Sedation with intestines and is excreted in the stools of Chlorpromazine 10 mg/ kg body weight humans and animals. The organism daily IV, Diazepam 1.5 to 2 mg/kg body produces exotoxins that are responsible for weight IV in 24 hours and Phenobarbitone 8 serious disease. Roadside dust and soil to 10 mg/ kg body weight in 24 hours. contains the spores and contaminated Rabies: Caused by a neurotropic wounds therefore cause tetanus. In the virus present in the saliva of dog, monkey, newborn baby, tetanus results from the fox, jackal, bat and many others. Infection umbilical stump which gets contaminated occurs from the bite of these animals. from the sickle or blade with which it is cut Incubation period is very variable, average in unhygienic rural or slum areas. It is one 1-2 months and range 10 days to a year. of the major causes of neonatal deaths in Closer the bites to the face, shorter the India. Widespread coverage with tetanus incubation period, thus highlighting the toxoid in the mother antenatally, need to vaccinate the patient promptly immunization after birth and use of a before the virus invades the brain.

85 Clinically: Tingling round the site of complex. The child may have no signs or may bite, thirst, fever, restlessness followed by have mild fever, poor appetite, feeling unwell maniacal behavior, dysphagia, and painful and slight enlargement of liver and spleen. In oropharyngeal spasms at attempts to some the infection may pass unnoticed. After swallow particularly fluids -hydrophobia. 6 to 10 weeks of primary complex, the child Terminally the patient develops convulsions, becomes sensitive to tuberculin test asphyxia, high fever, flaccid paralysis and (Mantoux's test). The skin test shows a coma. reaction of 8 mm or more of induration to 1 Treatment: Watch animal if pet or TU (tween 80) PPD which is considered capture if wild and watch for 10 days. If the positive. The test may be negative in seriously animal remains alive, Rabies is unlikely. If ill patients or those with malnutrition, due to the animal dies, or is not traceable, institute their depressed immunity. antirabic treatment promptly. The table Post primary spread occurs from below is a guide to treatment: extension in one of three ways from the In a previously vaccinated child, Duck components of the primary complex viz the embryo vaccine is indicated. For the local primary focus, regional lymph nodes or wound: after cleaning, application of through spread into the blood stream. This antirabic serum to depth of wound and ATS. spread can occur if the child's immune Tuberculosis: Causative agent is a status is poor as in malnutrition, measles, bacillus - mycobacterium tuberculosis. There whooping cough or chronic diarrhea or in are several other mycobacteria which are very young infants. Complications occur as not of significance to humans. The infection follows: (see Fig. 31-1, 2, 3) spreads mostly from an adult and less often = From the primary focus rupturing into from an older child having progressive lung the pleural cavity resulting in disease. Tuberculous pleural effusion (Fig. 31- The first illness is development of a 1b). primary complex which comprises a small = Enlarging regional lymph nodes that focus in the lung and an enlarged regional rupture into the lymph node (Fig. 23-1a). Together these two a) Pericardium causing pericardial (focus and gland) constitute the primary effusion (Fig. 31-2b) or

Nature of exposure At exposure During next Treatment recommended 10 days 1. No contact, indirect contact, Rabid None or contact with no lesion 2. Licks of skin, scratches or Suspected rabid Animal healthy Start vaccine, stop treatment abrasions, minor bites, if child healthy after 5 days (covered arms, trunk, legs) Animal rabid Start vaccine, Inj. Serum if diagnosis positive, complete the course 3. Licks of mucosa; major Suspicious rabid Serum and vaccine, stop bites, (multiple on face or animal treatment if animal remains head, finger, neck not available healthy after 5 days.

86 Fig. 31 : Complications of the primary tuberculous Complex : (A) From the primary focus; (B) Regional lymph nodes; (C) blood spread. b) Into the bronchus causing: lung ii) Tuberculous deposit in the disease and cavitation or brain rupturing into sub segmental spread and arachnoid space resulting in pneumonitis (Fig. 31-2a). tuberculous meningitis c) Spread into the blood stream (Early post primary) (Fig. 31-3) causing: iii) Bone and joint tuberculosis i.) Miliary tuberculosis with after months to several wasting, fever, liver and years (Late post primary spleen enlargement (Early infection) post primary complication) iv) Kidney tuberculosis in the 87 primary school age (with marked ascitis and edema out of proportion painless hematuria or sterile to the congestive failure; distant heart pyuria) (Late post primary sounds; engorged neck veins and pulsus infection) paradoxus. Also no other constrictive v) Reactivation of the lung pericarditis is known in children except lesion acquired at the time tuberculous. of primary infection or Diagnosis of tuberculosis in children reinfection from another depends on the region or system involved source (late onset) and investigations have therefore to be selected with discretion, taking into account, vi) Infection almost anywhere need for the test, cost involved and the in the body. parents' ability to afford. Following are The primary complex occurs early in commonly used diagnostic facilities Indian children because a large proportion available based on clinical suspicion: of the adult population is infected so that l Clinical suspicion; possibly Tuberculin the small child contracts the infection early. (Mantoux's) test; if a child does not In countries whose populations are less recover quickly after measles, infected or free from tuberculosis, primary whooping cough, diarrhea or other complex develops later, at adolescence or illness; unusual lesions, if painless and even later and the post primary slow to change; wasting or weight loss; complications (iii, iv and v above) occur still prolonged unexplained fever; later, in adulthood. unexplained liver enlargement; chronic Skin tuberculosis: Just like the primary painless non healing skin lesions; complex in the chest, skin also may have a lymph nodes that are enlarging or primary, consisting of a skin lesion and its matting; wounds that do not heal enlarged regional lymph node. As a late promptly and so on. complication, chronic slow growing, scabs l Routine side lab tests including blood may develop which are painless. Another counts, ESR, urine examination etc. lesion is an 'apple jelly' deposit- lupus l Sputum examination for tubercle vulgaris. Sometimes chicken pox like scars bacilli if the child produces phlegm are left behind after healing of small painless l skin lesions. Tuberculous ulcers may remain Radiological appearances in the chest chronic after healing of abscesses. (such as pleural effusion, pericardial effusion, collapse, mediastinal lymph Abdominal tuberculosis occurs in one of three forms viz. ascitic (with fluid in node enlargement, cold abscess abdomen), plastic form in which as a result related to rib), osteitis, osteomyelitis, of matting of bowel an abdominal mass dactylitis of tubercular origin. formation may occur and the third l Blood tests for PCR (Polymerase chain tuberculous enteritis with chronic diarrhea. reaction), TB specific Immunoglobulins Following a tuberculous pericardial IgA, IgM and IgG and gamma effusion (from bronchial gland rupturing interferon. into the pericardium), a constrictive l CSF examination in suspected pericarditis may occur. Diagnostic suspicion tubercular meningitis; pleural tap for of constrictive pericarditis comes from confirming nature of effusion etc. 88 l Needle aspiration (FNAC) or biopsy of a) Preventive therapy: In Mantoux lymph node or of skin for nature of positive asymptomatic young infants lesion to rule out tubercular pathology who are below 3 years, malnourished children, children in contact with an l Imaging techniques like adult patient:: ultrasonography of abdomen, CT scan of chest, brain etc as required. INH and RIF for 6 months b) Therapeutic treatment to the following Treatment depends on the nature, categories: Primary pulmonary severity and system involved. If primary complex, symptomatic MT positive tuberculosis is detected, this needs to be children below three years or above covered with Isonizid (INH) for at least 6 three years with malnutrition, isolated months or more. An adult contact must be lymphadenitis, pleural effusion INH+ looked for and adequately treated. RIF+ PZA for 2 months; INH+RIF for Treatment is available from the national 4 months programs and it needs to be assured that a c) Progressive pulmonary disease, child has completed the regime. Depends multiple Tb lymphadenitis INH + RIF upon the individual patient the clinician + PZA + EMB for 2 months and decides to treat with two and often with INH+RIF for 4 months three drugs. Those in common use are d) Miliary/Disseminated disease, cavitary Isonizid, Rifampicin, Pyrazinamide, disease/ bronchopneumonia, bone and Ethambutol, Injection streptomycin IM. joint disease, Abdominal/pericardial or There are others but used less often in genitourinary disease; children. The dosage is given empty INH+RIF+PZA+EMB for 2 months stomach and is as under: and INH+RIF for 7 months Isonaizid: (INH) 5mg/ kg body weight e) Brain tuberculosis (Neurotuberculosis) per day, single INH+RIF+PZA+EMB for 2 months morning dose. and INH+RIF for 10 months. Rifampicin (RMP) 10 mg/ kg body II. OTHER FREQUENT FEBRILE weight per day, single DISEASES morning dose Ethambutol: (EMB) 20 mg/ kg body Acute Rheumatic Fever (ARF) weight per day, single Cause: This disease occurs as a result morning dose of an immune disorder after infection with Pyrazinamide (PZA): 25 mg/ kg body group A beta hemolytic streptococcus of the weight per day, single throat that results in the production of antibodies against connective tissue and the morning dose heart (antigen antibody reaction). Its Inj Streptomycin (SM) 20 mg/kg body daily incidence has significantly fallen in India, intramuscular. most likely due to improved living The Indian Academy of Pediatrics conditions and antibiotics. working group has as per its consensus Clinical: Diagnosis is based on the statement, recommended the following revised Jones criteria that include five major regime in the treatment of tuberculosis in and four minor manifestations and children: unequivocal evidence of previous infection

89 with group A streptococcal infection. centers. Commonly seen over the Diagnosis is established with the presence of trunk and upper part of extremities. two major or one major and two minor 5. Subcutaneous nodules: Firm, criteria. There is history of a preceding sore painless, about 1 cm diameter over the throat about 3 weeks before manifestations extensor surfaces of tendons near of a general nature- malaise, irritability, bony prominences. fatigue, abdominal pain and epistaxis. The four minor manifestations The five major manifestations include: include: 1. Polyarthralgia (alone without 1. Polyarthritis: Involves more than polyarthritis). one joint; swollen, tender and warm 2. Fever. on palpation. The joint involvement is 3. Elevated acute phase reactants 'fleeting' and 'flitting' which means that (ESR and CRP). it does not stay in one joint longer than a few days and moves to another 4. Prolonged P-R interval- though not joint (Also see under Joint swelling in alone an evidence of carditis. section 4). This promptly responds to Unequivocal evidence of recent Group salicylates which can be considered a A streptococcal (GAS) infection: therapeutic test for the diagnosis. Raised/ increasing streptococcal 2. Carditis: Tachycardia antibody titers: antistreptolysin O (ASLO), disproportionate to degree of fever; anti D-nase B, and antihyaluronidase. Thus pericarditis indicated by a pericardial measurement of three different antibodies rub or effusion; presence of a murmur confirms the diagnosis. of mitral or aortic regurgitation; Note : GAS antibodies may be cardiomegaly; congestive cardiac increased in any child with GAS pharyngitis failure with gallop rhythm and and by itself this does not constitute the enlarged heart. diagnosis of Acute Rheumatic Fever (ARF). 3. Sydenham's chorea: Characterized Presence of Jones criteria together with by purposeless involuntary movements, presence of these antibodies is essential for incoordination and emotional lability, diagnosis. hypotonia, facial grimacing more Treatment of Acute rheumatic fever common in girls in the prepubertal age. Some characteristic features are: l Bed rest and monitoring for carditis at 'milkmaid's grip' (alternate contraction least until acute phase reactants and relaxation of grip); 'Trombone normalize. tongue' (wormlike, darting movements l Immediate treatment with oral of tongue when asked to protrude); erythromycin or Penicillin for 10 days Spooning and pronation of or one injection of Benzathine outstretched hands; poor handwriting- Penicillin to root out throat infection often used to check progress of disease. with group A streptococcus (GAS). Takes several months to recover. l This should be followed with 4. Erythema marginatum: prolonged prophylactic administration Erythematous, macular, serpiginous of Penicillin. non itching annular rash, with pale l Salicylates are prescribed to patients 90 with migratory polyarthritis or carditis: on. After a few cycles some merozoites Initially 100 mg/kg per day in four change into male and female sexual forms divided doses X 3 days and then 75 called gametocytes. These are ingested by mg/kg/day for 4 weeks for their anti- the mosquito and form sporozoites ready to inflammatory action. infect a human host. P vivax parasites may l Corticosteroids if carditis, behave differently within the liver cells. cardiomegaly or congestive failure at Instead of multiplying they remain dormant the rate of 2mg /kg of Prednisolone q in the liver for varying periods and then 4 times for 3 weeks and then in become active liberating merozoites and tapering doses thereafter. causing a malarial relapse. Clinically malaria presents in a wide variety of forms- l In cases of carditis and cardiomegaly: asymptomatic, mildly symptomatic and add to salicylates digoxin, diuretics severe. P falciparum is likely to present in and oxygen severe forms with complications. Treatment: Long term prophylaxis: Clinical: In children presentation is Benzathine Penicillin (12 lac units) every different from the adult. Instead of the well three weeks, or oral Penicillin V twice a day. known classical bouts of fever with chills In Penicillin sensitive children erythromycin/ and rigors, in adults, children have an sulfadiazine bid can be given orally. The irregular fever with gastrointestinal and duration of prophylaxis is as under: respiratory symptoms. The clinical picture l Rheumatic fever alone: till age of 21 varies with age: The disease is mild in years. young infants. In toddlers and preschool l Rheumatic fever with carditis: At least children, it usually begins with a cough, for 10 years, or more. 'cold' or flu like symptoms, loose motions, vomiting, abdominal pain or even febrile l Rheumatic fever with carditis and seizures. In older children, the onset may be valvular disease: Until at least 40 years like adult disease- with classical periodicity, of age or life long. bouts of fever followed by sweating. In Malaria falciparum infections the classical fever pattern does not occur, instead, the fever is Cause: Malarial parasites of the irregular. Hepatosplenomegaly and anemia plasmodium family, most commonly P vivax occur frequently. Severity of disease and P falciparum and sometimes P ovale depends on degree of parasitemia. Vivax and P malariae are responsible for human malaria causes hyperpyrexia, anemia, and disease. Man and mosquito serve as the mild icterus from hemolysis. Falciparum hosts. disease is more serious and manifests as The malarial life cycle: female generalized seizures and coma (as a result of anopheles mosquito injects sporozoites cerebral involvement from sequestration of while it bites a human for a blood meal; brain micro vessels), anemia, metabolic sporozoites multiply asexually in liver cells changes (hypoglycemia, fluid/electrolyte and in a few days liberate merozoites into disturbances, and acidosis), the circulation; these divide into daughter hemoglobinurea, renal failure, respiratory merozoites which rupture and invade red distress, shock. blood corpuscles; rupture of red cells frees Treatment: See table below: merozoites to invade more red cells and so 91 Name of drug Indications Dosage Chloroquine 250 mg Vivax Malaria and uncomplicated Falciparum: 10mg/kg base stat, 5mg/kg equivalent to 150 mg Suppressive therapy for Vivax infection after 6,24 & 48 hours base Syrup available Severe cases, drug resistant cases p.o Single dose (10mg/kg) weekly for upto 3 months IV 5mg/kg base in isotonic saline, slow drip spread over 6 hours. Quinine Sulphate Tabs Chloroquine resistant uncomplicated 10mg/kg tid x 7 days p.o. In 100, 300 & 600mg. Falciparum infection severe cases IV 10 mg/kg in Syrup 100 and dextrose solution spread 150mg/5ml over 6 hours, 8 hourly till oral dose can be given. Sulphadoxin (500 mg) Chloroquine resistant uncomplicated 20mg/kg Sulphadoxin 1 mg/ pyrimethamine (25 mg) Falciparum infection kg PyrimethamineSingle oral Combination Syrup dose available. Primaquin Tab 250 mg. Prevents relapse of Vivax infection Base: 0.3 mg/kg/day p.o for (recommended for non endemicregions) 5 days Gametocidal for Falciparum 0.7mg/kg single dose p.o (interrupts trans-mission). Mefloquine Tab250mg Multi drug resistant Falciparum. 15 mg/kg single dose p.o For prophylaxis of chloroquine resistant cases 3.5mg/kg base p.o weekly Artemesinine Syrups Useful in all kinds of malaria 4mg/kg/p.o on day one, available 12mg/kg/ day for 4 days. See dosage schedules of different preparations I.V 10mg/kg total dose spread over 5 days followed by 2mg/kg for the next 3-6 days

Leishmaniasis (Kalazar) splenic puncture, bone marrow study or by Cause: A parasitic disease caused by lymph node biopsy. The parasite is Leishmania donovani. It is seen mostly in demonstrated by culture from affected epidemic form in certain areas of Bihar, tissue. Diagnosis is also made by West Bengal and Assam. The insect vector is polymerase chain reaction (PCR); serology- a sand fly in whose gut the parasite fluorescent antibody test and by ELISA test. multiplies and finds its way- (through the Associated lab findings are anemia, bite of the fly) into the human reticulo nutropenia and thrombocytopenia (from endothelial tissue resulting in hepato- pancytopenia) and hyperglobulinemia. If splenomegaly.The incubation period is upto untreated, a large majority of patients die. 4 months. Treatment: Pentavalent antimony - Clinically: Fever, nose bleeds, Sodium antimony gluconate, I.V 20 mg/kg/ darkening/blackening skin and limbs, day single dose daily for 2-3 weeks, until ('Kalazar') recurrent history of fever and patient is free of parasites as determined by malnutrition are usual. Diagnosis is made by bone marrow or splenic aspirate. In the 92 event of failure, IV infusion of Amphotericin (submandibular, cervical etc.). B in a dose of 1mg/kg/day can be given for Recovery sets in, in about a week or 20, days. two. Prevention: Spraying against sand l Herpes labialis: flies. Relapses tend to occur in endemic Burning in the area where herpetic regions hence the need for intensive case lesions are likely to appear, precedes detection and treatment of the infected. the actual lesions some hours before. Herpes Simplex Initially erythematous papule over lips, evolve quickly into vesicles and then Cause: Herpes simplex virus 1 and 2 shallow ulcers and finally scabs. (HSV 1 and HSV 2). The two have a similar Recovery occurs in about a week or genetic composition. The infections are more. usually mild and short lived except in the l Skin lesions: neonate and an immunocompromised person. The infections are not confined to Usually occur at the site of trauma and any geographic region or season. There is abrasions over the skin with burning some degree of cross immunity between the tingling etc. Initially erythematous two virus types. The oral cavity, the genital papules appear over the areas which tract, the skin and the eye are commonly evolve quickly into vesicles and then involved. Fetal and neonatal disease is shallow ulcers and finally crusted serious and often fatal. Their incidence is on scabs. Regional lymph nodes enlarge. the rise as a result of increasing genital A larger area than labial herpes is herpes in the mother. HSV can cause fatal involved and lesions can be recurrent. encephalitis, occurring sporadically. Infection can be very severe and even fatal, if eczema coexists with skin Clinically: A variety of lesions can herpes (eczema herpeticum) as a result occur. Typical lesions are in the form of 1-2 of dissemination of infection unless mm vesicles surrounded by erythema. In a prompt treatment is instituted early. few days the rash develops into shallow Herpetic paronychia (whitlow): ulcers with much less erythema. However, Commonly the result of thumb sucking depending upon the host immunity, the from infected oral herpes. Painful and anatomic site and whether it is first time or a tender finger nails, recover in about repeat infection, atypical lesions may occur three weeks. in some patients, like fissures or l nonvesicular erythematous or often Genital herpes: unrecognizable lesions. Occurs from sexual contact in l Mouth and throat infection: adolescents or in neonates during delivery, from genital herpes in the Gingivostomatitis: pain, drooling, mother. The nature and evolution of inability to take food from painful the lesions is more or less same as in lesions, fever. Vesicles appear over oral, labial and skin infection viz lips, gums, tongue, palate and throat, papules, vesicles, shallow ulcers and including tonsils and pharynx. As a crusting before final recovery. result of oral lesions, which develop in l to ulcers, halitosis and Ocular herpes: lymphadenopathy of the region occurs Keratoconjunctivitis is a common 93 manifestation of eye infection and is application started early is associated with conjunctival edema effective. and blepharitis but no purulent Infectious Mononucleosis discharge, although the regional preauricular gland is enlarged. Cause: Epstein - Barr virus (EBV). Herpetic vesicles can be seen on the Similar syndrome is caused by lid margin. Lesions clear in less than a Cytomegalovirus (CMV), Toxoplasma month. Corneal involvement is Gondii, HIV, Hepatitis virus and uncommon. Adenovirus. In EBV negative type of l Herpetic encephalitis: infectious mononucleosis cause is unknown. Incubation period is one or two months. Presents with fever, headache, nausea, vomiting, neck rigidity, sensorial loss, Clinically: Fever; enlargement of and seizures. CSF shows a picture of glands, mostly in the neck (anterior and aseptic meningitis. About three posterior cervical) mandibular and quarters of cases with herpetic epitrochlear (very suggestive of diagnosis); encephalitis may end fatally. severe pharyngitis with sore throat, exudative tonsillitis, splenomegaly; l Neonatal herpes: maculopapular rash in a few. A It may be in utero, acquired during characteristic phenomenon is the passage from infected birth canal or appearance of a rash following medication after birth from mother or another with this Amoxicillin or Ampicillin in a adult suffering from herpes. Symptoms majority of the patients. after birth include vesicles and scarring of skin, choreoretinitis kerato Diagnosis: Suggestive clinical picture; conjunctivitis, microcephaly, Absolute leucocytosis with majority (upto 40 encephalitis or meningitis. Unless percent) atypical lymphocytes. Serology is treated, these babies could go into done for presence of heterophile antibodies shock, disseminated intravascular and specific antibodies against the EBV. coagulation (DIC). Most infants die Treatment: None specific. Bed rest, and those that survive have severe supportive and nursing care. After recovery neurological handicaps. the child should avoid strenuous exercise for Diagnosis: This is made from fear of splenic rupture- a possible v Clinical, examination and complication. Acyclovir and steroids are appearance of lesion. useful in selected severe cases. v Virus isolation or antigen Cytomegalovirus (CMV) detection Cause: A virus of the herpes virus v Polymerase Chain Reaction group. Its distribution is world wide with (PCR) test for HSV viral DNA. higher prevalence in poor communities. The Treatment: sources of virus transmission are saliva, urine, blood, stools, vaginal secretions and v Acyclovir is readily available in breast milk. Thus transmission is congenital, oral (suspension) and in local perinatal, person to person and from application forms. Oral fomites. medication needs frequent dosing and is very safe. Local Clinically: Symptomatology depends

94 upon age and immunocompetence of the predisposing to multiplication of the patient and the route of transmission. mosquito in fresh water, coolers and other l Congenital infection: Most newborns storage places. have only sub clinical infection. Some Clinical: Children are more likely to be asymptomatic babies may have affected. The illness has a wide spectrum, sensorineural deafness. In a small ranging from asymptomatic mild fever to proportion of severely affected cases, severe disease with hemorrhage and shock. intrauterine growth retardation, Two major forms of the disease have been prematurity, liver and spleen identified- Dengue fever and Dengue enlargement, jaundice purpura, hemorrhagic fever sometimes with shock microcephaly and intracranial (Dengue shock syndrome). calcification are seen. Dengue fever (DF) occurs after a brief l Perinatal infection: Occurs from incubation of upto one week, with sudden maternal genital infection during onset of high fever, severe body aches and passage through the birth canal and pains in the form of headache, severe eye subsequently from breast milk. Usually pain, back ache, muscle and joint pains, babies are asymptomatic at birth but abdominal colic, loss of appetite, feeling of some may develop pneumonia and extreme weakness and a fading sepsis. Neurological signs- maculopapular rash. Petechial and developmental retardation may occur. ecchymotic hemorrhages may occur with l In immunocompromised patients leucopenia and thrombocytopenia. clinical manifestations include Recovery takes upto a week or more and pneumonitis, choreoretinitis, fever, seems complete. gastroenteritis, leucopenia, hepatitis Dengue Hemorrhagic Fever (DHF): In pancreatitis and cholecystitis. These mild cases, fever, hemorrhages and liver may become generalized and fatal. enlargement occur. Bleeding occurs as a Diagnosis: purpuric rash, epistaxis and gastrointestinal bleeding. l Virus culture from saliva, urine, breast milk, vaginal secretions or biopsy At the time of defervescence, a series material of changes occur thus: Intracellular viral l death- vasculopathy- extravasation of Polymerase Chain Reaction (PCR) plasma through blood capillaries- Dengue hemoconcentration- hypovolemia- hypotension. If extravasation is not Cause: Virus transmission to humans prolonged, recovery occurs. However if by the bite of the insect vector, a mosquito, plasma leakage is severe and persistent, the Aedes egypti. The virus has several species patient may go into shock - Dengue Shock and the infection they produce does not Syndrome (DSS). Thus a patient should be provide cross immunity. Severe epidemics carefully followed up as defervescence sets have been occurring in many parts of the in as this is the time when DSS may set in. world and seem to be on the rise. In India outbreaks of the disease began in the 1980's Diagnosis: There is no specific test for and have since been occurring frequently, diagnosis of Dengue. Suspicion should arise seemingly as a result of demographic if during a known epidemic or epidemic changes, population overgrowth, crowding, season (soon after monsoons) a child has poor housing and water storage fever. Bleeding tendencies could be revealed 95 by a positive Tourniquet test. A drop in adolescents it is transmitted sexually platelet count and rise of PCV (suggesting (heterosexual as well as homosexual). hemoconcentration) are strongly suggestive Acquired infection occurs from transfusion of DHF. of infected blood or from use of Treatment: Monitoring requirements contaminated injection needles, drug abuse will determine line of management. or from infected wounds. For patients of DF who do not have For details of pathogenesis, the reader hemorrhages and shock: is referred to standard text books on the l subject. A brief, simplified account appears For pain and fever: Paracetamol 15 here. The virus genome is a single stranded mg/kg dose repeated as required but RNA and its various regions contain virus do not repeat in less than 6 hours. enzymes and encode viral core and viral l Plenty of fluids orally. envelope proteins. The virus binds l Hospitalize if fever does not settle or selectively to T4 lymphocytes (CD4+ cells patient gets worse after fever seems to responsible for immune responses) and other protective cells. The viral particle in be subsiding, has a drop of blood the process releases RNA which in turn pressure, diminished urine output, cold produces DNA. The DNA of the cell is extremities, is restless or anxious or broken and the new DNA of the virus feels drowsy. (provirus) is inserted into the cell which For patients of DHF: makes copies of the virus. These virus l Immediate administration of IV fluids copies leave the cell to infect other cells, with careful and continuous killing or permanently infecting them. Thus monitoring of fluid input and urinary inactivation of immune mechanisms by the output round the clock, blood pressure HIV results in devastating effects. Viremia, l as a result of free circulation of the virus, Platelet transfusion in patients who then spreads to various organs. The virus have bleeding with thrombocytopenia. bound CD4+ cells invade lymph nodes, l In patients who may develop a cardiac where they multiply, and cause generalized overload during treatment, lymphadenopathy. As a result of some fight decongestive therapy is required put up by the dwindling humoral and (Digitalis and diuretics). cellular response the infection enters a latent phase in about a few weeks to a few Human Immunodeficiency Virus months. During this seemingly 'latent' phase (HIV) in children: a slow but definite destruction of the Cause: HIV belongs to a retrovirus immune system continues resulting in family. The disease is commonest in sub destruction of the lymph nodes and their Saharan Africa followed by South and ability to trap the virus particles which then South-East Asia (India, Thailand, Vietnam, circulate freely producing a second phase of Cambodia and China). There are over 40 viremia with consequent widespread illness million suffering people in the world. In thereafter involving multiple systems. India half of all infected people are women Clinically: There is a wide variation and children. The disease is caused by the depending on age and the extent of immune human immunodeficiency virus (HIV). It impairment assessed by CD+ lymphocyte occurs from antenatal infection in infected count. Younger the child at the onset of the mothers, through breast milk and in disease, severer and faster is the course of 96 the disease with early complications and pathy, malignancy, disseminated death. In the newborn, no obvious findings mycobacterial infection, Pn. may be present or symptoms may be Carinii pneumonia, cerebral nonspecific. Any prolonged infection, toxoplasmosis and severe weight particularly candidiasis, failure to thrive, loss. For suspected disease in the chronic diarrhea should arouse strong newborn from perinatal exposure suspicion. an 'E' is prefixed to the The Center for Disease Control (CDC) classification. classification is based on two parameters: Thus, for example, a given case with (1) Age adjusted CD+ lymphocyte counts. severe (less than 15% CD+ lymphocyte The three categories of CD+ count-category 3), and belonging to clinical lymphocyte are: category B will be labeled as B3 in the CDC classification and so on. This helps in v Category 1, Normal counts assessment and prognostication. (more than 25 %), Opportunistic Infections: As a result of v Category 2, moderate fall (15- 24%) and impaired immunity (fall in CD+ lymphocyte v count), opportunistic infections and illnesses Category 3 severe fall (below 15 appear during the illness. These include %) l Parasites: Pn. carinii, malaria. (2) The categories of signs and symptoms l are: mild (A), moderate (B), and Fungi: candidiasis, cryptococcosis, severe (C), based on severity of illness: cryptosporidiosis. l v Category-A Mild symptoms: At Bacteria: atypical mycobacteria, least two mild symptoms e.g., Mycobacterium Avium Cellulare, lymphadenopathy, parotitis, tuberculosis hepatomegaly, splenomegaly, l Viruses: Herpes simplex and zoster, dermatitis, and recurrent/ cytomegalovirus, measles. persistent sinusitis/otitis media. l Protozoal: Toxoplasmosis. v Category B Moderate symptoms: l Lymphocytic Interstitial Pneumonia Lymphoid interstitial pneumonia, (LIP) is of unknown etiology and is a persistent oropharyngeal frequent opportunistic lower candidiasis for more than 2 respiratory infection in infants. months, recurrent/chronic l diarrhea, persistent fever over 1 Among neoplasias, rarely seen in the month, hepatitis, recurrent disease are certain lymphomas. herpes simplex stomatitis/ Diagnosis esophagitis/ pneumonia, l Elisa for IgG antibody, reliable after disseminated Varicella. the age of about 2 years. v Category C Severe symptoms: l Western blot test after age of 6 Two serious bacterial infections months after a prior test to within two years, (sepsis/ confirm HIV. meningitis/pneumonia), esopha- l geal or lower respiratory Polymerase Chain Reaction candidiasis, cryptococcosis, (PCR)- most reliable but cryptosporidiosis, encephalo- expensive 97 l Lowered CD+4 and raised Toxoplasmosis CD8+ counts Cause: Infection from a protozoan- Treatment: Toxoplasma gondii. It produces disease by Specific therapy is grouped as under: multiplying intacellularly in humans, mammals and birds. Cats are the most (a) Nucleotide Reverse Transcriptase common source of the disease transmitted Inhibitors (NRTI) such as Zidovidine, to them from eating infected meat and Lamivudine, and Stavudine etc. excreted in the stool. Contaminated soil (b) Non Nucleotide Reverse Transcriptase contains oocysts that have matured in the Inhibitors (NNRTI) such as Nevirapine, cat intestine. Infected meat from lamb, pork Delavidine etc. and beef can cause toxoplasmosis. (c) Protease inhibitors: Such as Ritonavir, Congenital infection though rare occurs if Nelfinavir. mother is infected between second and six months of pregnancy. (d) A combination consisting of two NRTI drugs and a protease inhibitor is Clinically, the disease may vary from grouped under the term 'Highly Active asymptomatic to wide manifestations Antiretroviral Therapy' (HAART) depending upon the immunocompetence of the infected person. Prematurity, early (e) Prevention of transmission from jaundice (first or second day), purpura, mother to baby: hepatomegaly, choreoretinitis may occur. v Zidovidine to pregnant mother Surviving infants may have neurological from 14 to 34 weeks (100 mg disease- epilepsy, visual defects, intracranial oral five times daily) infection etc. v Zidovidine during labor 2mg/kg Diagnosis: can be made from: Blood I.V. spread to one hour and then or tissue culture for organism; biopsy for 1mg/kg/hour until delivery. tissue cysts; specific serologic tests; v Zidovidine 2mg/kg p.o repeated agglutination test for IgG antibodies; and 6 hourly from 8 hours of birth to Elisa (IgM) 6 weeks postnatal. Treatment: Sulphadiazine- v Restricting breast feeding Pyramethamine combination. In some situations, Spiramycin. v Caesarian delivery. (For details of drug therapy, dosage, Leprosy side effects etc. look up a reference text Cause: Mycobacterium leprae. India is book). still reported to be an endemic country for leprosy contributing nearly two third of the Other measures: total world cases. UP and Bihar have the These include community measures largest number (41 per cent of the total in and support to prevent spread of disease, India) while many other states contribute 3 such as sex education in the use of to 8 percent each of the remaining. condoms, education and counseling against Transmission is mostly by inhalation from drug abuse, nutritional care and hygienic nasal secretions of an infected patient measures. The stigma of the disease and its through droplets after prolonged contact. social implications call for appropriate help Thus close family members are most likely and support. to be infected. An infected nursing mother

98 can transmit it to her baby through her diminished sensations and hair breast milk. The incubation period is on the patch. Lepromin test prolonged- between less than a year upto 20 negative years with an average of 3-5 years. The v Borderline lepromatous (BL) social stigma associated with the disease is leprosy: There are many shiny age old and has been responsible for spread lesions with slightly diminished of the disease. For this reason the term sensations and hair over the 'leper' has been replaced by labeling a patch. Bacilli often found from patient as a 'leprosy patient' or 'Hansen's the lesion but lepromin test is disease'. negative. Clinically: Skin and the neural tissues l Lepromatous (LL) leprosy: Most are the most affected. Earlier the detection infectious but fortunately uncommon more effective and prompt is the cure. Early in children. There are innumerable detection is therefore important. Sensory small, shiny lesions with no sensory disturbances (loss of sensation, numbness, disturbance and normal hair growth in 'pins and needles' etc) over a light or pink the lesion. The lesions vary, may be patch of skin are highly suspicious as also macular, popular, nodular or pink areas of some thickening of skin combined. The typical leonine facies is especially over face and hands. A sensory the result of diffuse thickening and skin disturbed patch together with a thickened infiltration with loss of eyebrows and nerve in the region is almost pathognomonic deformed ear lobes. Nasal symptoms of leprosy. Sometimes ulcers may appear appear early and include congestion, early on fingers. Indian workers have crusts and bloody discharge from the classified the disease into five major groups: nose. Pedal edema often occurs Indeterminate (IL), tuberculoid (TL) towards the end of the day. borderline (BL), lepromatous (LL) and pure Other clinical characteristics: neural tuberculoid. Neural features: Characteristics of skin lesions various l forms of leprosy: Tuberculoid leprosy: The skin patch l shows loss of sensation. The nerve in Tuberculoid (TT) leprosy: Usually a the region of the skin lesion is single lesion with a raised margin, dry, thickened. often scaly, absence of hair growth, l sensory loss in the patch. Skin smears BT leprosy; There is marked do not show any bacilli but the diminution of sensation in the skin lepromin test is positive. This the lesion. There may be thickening of commonest type in children. more than one superficial nerve. l BB leprosy: Marked diminution of skin l Borderline leprosy: sensation. v Borderline tuberculoid (BT) l BL leprosy: Mild sensory loss. Nerve leprosy: Only a single or a few trunk not thickened. dry lesions, diminished sensation, no hair over the patch. l LL leprosy: Skin lesions do not have Lepromin test is weakly positive sensory loss. A sensory neuropathy may develop with increasing severity v Borderline mild (BB) leprosy: of the disease. There may be several, shiny l lesions, with moderately In a neuritic form of leprosy there may 99 be no skin lesions but nerves are Clarithromycin, some Quinolones have directly infected with thick and tender shown promise in experimental animals but nerve trunks. Absence of sensations sufficient human data is not yet available in leads to ulcers, eye complications and this regard. Individually drugs are known to other deformities. Nerves affected produce resistance so that multidrug regimes commonly are the ulnar and median in are employed and have given good result. the upper limbs and popliteal and Treatment is carried out for a period of two tibial in the lower. to three years while monitoring relapses. The dosage is as under: Reaction lesions: Certain reactions occur from host- Toddlers & School Above parasite immune changes. These are Preschool age (3-5) 5-15 15 exacerbations and may occur in the form of "Reversal reactions" or "Erythema nodosum Dapsone 25 mg 50-100 mg 100 mg leprosum reactions" daily Reversal reactions: Tenderness and Rifampicin 150- 300- 600 mg monthly 300 mg 450 mg swelling of lesions and permanent nerve damage in borderline cases. Clofazimine Supervised 100 mg 50-200 mg 300 mg Erythema nodosum type: (Monthly) Hyperpyrexia, multiple joint pains, Unsupervised 100 mg 150 mg 50 mg lymphadenitis, orchitis and Iridocyclitis. This weekly weekly daily occurs in lepromatous cases. For reactions, antimony (IV), Diagnosis: This is made from clofazimine, chloroquine and steroids (oral) appearance an examination of the skin are used. lesions described above, sensory disturbances in the skin lesions, thickness of Prevention: Intensive leprosy nerves and demonstration of acid fast bacilli eradication in the community is the only hope. in skin lesions and nasal secretions. BCG in booster doses has been effective. Fluorescent antibody absorption test is very specific as a diagnostic tool and confirms M III. INFECTIONS IN THE NEWBORN leprae antigen. A radioimmunoassay (See section 3B) determines antigen of the cell wall of the bacterium. There are several other tests but IV. SYSTEMIC INFECTIONS AS they lack specificity particularly in CAUSE OF FEVER paucibacillary forms of infection. (See related symptom in Section 4) Treatment: In view of slow For gastroenteritis, appendicitis, liver improvement, poor compliance to long term abscess, pancreatitis, cholecystitis etc. : therapy and poverty among most leprosy Chapters 11 (Abdominal pain) and 12 patients, there is need to follow the program (Abdominal distension) of treatment with considerable dedication, perseverance, good patient communication, For urinary tract infections : Chapter supervision and follow up on the part of 13 (Urinary Symptoms) health workers. For hepatitis : Chapter 14 (Jaundice) Drugs in use for multibacillary leprosy For respiratory infections : Chapter 19 include Dapsone, Rifampicin and (Cough), Chapter 20 (Wheezing), and Clofazimine. Others e.g. Minocycline, Chapter 21 (Stridor) 100