Textbook of Pediatric Nursing [First Edition] 9349057271, 9789349057272

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UNIT I - INTRODUCTION: MODERN CONCEPTS OF CHILD CARE

Chapter 1: Child Care Concepts • • • • • • •

Introduction Historical Perspectives on Child Care Practices Health Care Delivery System in India National Policies, Legislation and Agencies Related to Child Welfare National Health Programs Related to Children Internationally Accepted Rights of the Child Changing Trends in Child Health

Important Topics

Introduction Administration of Medication: Oral Administration of Medication: IM Calculation of Fluid Requirement Calculation of Drop Rate Application of Restraints Pain Assessment in Children

UNIT II - THE HEALTHY CHILD

Chapter 5: Development Theories and Physical Examination

Chapter 2: Preventive Pediatrics • • • • • • •

• • • • • • •

• •

Introduction Immunization Vaccines Under Five-Clinics/Well Baby Clinics Child Morbidity and Mortality Infant Morbidity and Mortality Accidents in Young Children

• • •

Introduction Principles and Factors Affecting Growth and Development Developmental eories Development Assessment Pediatric History and Physical Examination

Chapter 3: Hospitalized Child • • • • • • • • •

Differences between Children and Adults Hospital Environment for a Sick Child Impact of Hospitalization on Child Nursing Care of a Hospitalized Child Effects of Hospitalization on Family Grief and Bereavement Role of a Child Health Nurse Ethics in Pediatric Nursing Principles of Pre- and Postoperative Care for Children

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Chapter 9. Management of Neonatal Conditions

List of

Figure 9.10: Flowchart for management of neonatal seizure

High Yield Topics

132

UNIT IV - INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS (IMNCI) Chapter 11. Management of Sick Children—2 Months to 5 Years

Figure 11.1: IMNCI case management process for sick child age 2 months up to 5 years

154

UNIT VII - DISEASE CONDITIONS–I Chapter 16. Hematological Disorders

Figure 16.5: Hemophilia inheritance

250

UNIT VIII - DISEASE CONDITIONS–II Chapter 21. Musculoskeletal Disorders

Figure 21.12: Tensilon test UNIT I - INTRODUCTION: MODERN CONCEPTS OF CHILD CARE Chapter 1. Child Care Concepts

Figure 1.2: Anemia Mukt Bharat Table 1.1: Major elements of RCH program Figure 1.3: 4Ds of Rashtriya Bal Swasthya Karyakram

8 12 14

348

Chapter 22. Disorders of Skin, Eye and Ear

Figure 22.1: Figure 22.3: Table 22.2: Figure 22.7:

Fungal infection in children Types of lice Speci c eye problems in children Tympanostomy tubes in eardrum/tympanic membrane

355 357 358 363

Chapter 2. Preventive Pediatrics

Table 2.1: National immunization schedule Figure 2.3: Sustainable development goals

20 24

Chapter 4. Child Health Nursing Procedures

Table 4.1:

IM Administration: Location, needle length, gauge, amount of uid

38

UNIT II - THE HEALTHY CHILD Chapter 5. Development Theories and Physical Examination

Table 5.6: Audiologic tests for infants and children Figure 5.14: Deep tendon re exes

Chapter 23. Communicable Diseases

Table 23.1: Figure 23.1: Figure 23.2: Figure 23.5: Figure 23.6:

Overview of communicable diseases Structure of HIV HIV life cycle COVID-19 symptoms in children Guidelines for management of COVID-19 in children Figure 23.7: Management of multisystem in ammatory syndrome in children (MIS-C)

68 70

364 366 367 372 373 374 and Many more...

UNIT III - NURSING CARE OF NEONATE Chapter 7. Normal Newborn

Figure 7.1: Resuscitation procedures and proportions of newborns who need them

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Jyoti Sarin

PhD (N), MSc (Pediatric Nursing), BSc (Hons.) Nursing

Dean – Faculty of Nursing Director, Principal MM College of Nursing Maharishi Markendeshwar University Mullana, Ambala, Haryana

Smriti Arora PhD (N), MSc (Pediatric Nursing), BSc (Hons.) Nursing

Professor cum Principal College of Nursing All India Institute of Medical Sciences Rishikesh, Uttarakhand

CBS Publishers & Distributors Pvt Ltd • New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Lucknow • Mumbai • Hyderabad • Jharkhand • Nagpur • Patna • Pune • Uttarakhand

Disclaimer Science and technology are constantly changing fields. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies.

eISBN: 978-93-490-5727-2 Copyright © Authors and Publisher First e Book Edition: 2023

All rights reserved. No part of this eBook may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher. Published by Satish Kumar Jain and produced by Varun Jain for CBS Publishers & Distributors Pvt. Ltd. Corporate O ice: 204 FIE, Industrial Area, Patparganj, New Delhi-110092 Ph: +91-11-49344934; Fax: +91-11-49344935; Website: www.cbspd.com; www.eduport-global.com; E-mail: [email protected] Head O ice: CBS PLAZA, 4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi-110002, India. Ph: +91-11-23289259, 23266861, 23266867; Fax: 011-23243014; Website: www.cbspd.com; E-mail: [email protected]; [email protected].

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About the Authors Jyoti Sarin PhD (N), MSc (Pediatric Nursing), BSc (Hons.) Nursing, is Dean – Faculty of Nursing, DirectorPrincipal of MM College of Nursing (Deemed to be University), Mullana, Ambala (Haryana), India. She completed her graduation in 1985, and post-graduation in 1995 with Pediatric Nursing specialization. She did PhD in Nursing in the year 2005 from RAK College of Nursing, University of Delhi. Dr Sarin has been awarded President of India Silver Medal for academic excellence in BSc (Hons) Nursing and President of India Gold Medal for Master of Nursing. She has also been awarded TK Adrenwala prize for the best work done in research in Masters in Nursing Dissertation. During her 36 years of illustrious teaching services, she is associated with baccalaureate, postgraduate and PhD Nursing programs. She has a significant number of published works to her credit. Apart from this, the author has participated and presented papers in various workshops at State, National and International level. She had been a member of the core group for development of Standards for Nursing Practice Quality Assurance Model WHO project. She has participated in international practical training course on Quality Assurance in Health Care at Indonesia and SIDA’s Program in child survival at Sweden and Vietnam. Last but not least, she is President for Indian Association of Neonatal Nurses, Certified national trainer for Neonatal Resuscitation Program; Integrated Management of Neonatal and Childhood illness and virtual capacity building program for midwifery faculty organized by INC & UNFPA. Smriti Arora PhD (N), MSc (Pediatric Nursing), BSc (Hons.) Nursing, is currently working as Professor cum Principal at College of Nursing, AIIMS, Rishikesh, Uttarakhand. She has work experience of more than two decades. She completed her BSc (Hons) Nursing, MSc (Pediatric Nursing) from College of Nursing, AIIMS, New Delhi, and PhD (Nursing) from National Consortium, Indian Nursing Council and Rajiv Gandhi University of Health Sciences. She has previous work experience at Amity University Haryana, Jamia Hamdard and AIIMS, New Delhi. She is a recognized PhD Nursing Guide at Indian Nursing Council. She has mentored and guided more than 35 postgraduate nursing students. She has also participated as a ‘Mentor’ in the training program “Nationwide Capacity Building of Nursing Professionals for Comprehensive Management of COVID-19 in Children” organized by the Government of India. Dr Smriti Arora has been appreciated by Indian Academy of Pediatrics for her contribution to Basic newborn care and resuscitation program. She is a National Trainer for COVID-19 Pediatric care, Nationwide Neonatal Resuscitation Program and HIV/AIDS. She is also recognized as a national mentor for the flagship LaQshya program across India and an active member of Nationwide Quality of Care Network (NQOCN). She also participated as a co-investigator in the project titled ‘Enhancing Quality of Midwifery Education in Bihar’ supported by UNFPA. Apart from organizing more than 50 workshops and conferences, she is an active member of many professional bodies like TNAI, IANN, NNF, PNNFI, SPHERE and CNRS. Last but not least, she has authored a couple of books and published more than 50 articles in national and international journals.

Contributors and Reviewers Contributors Amrita A Sivasanker Assistant Professor School of Nursing Sciences and Research Sharda University Greater Noida, Uttar Pradesh Anjali Kaushik Tutor Jamia Hamdard New Delhi Bhargavi CN Associate Professor Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr RML Hospital New Delhi Binita Mishra Tutor College of Nursing All India Institute of Medical Sciences Deoghar, Jharkhand Hepsi Bai Joseph Assistant Professor College of Nursing All India Institute of Medical Sciences Bhubaneshwar, Odisha Ibanrilin Rane Assistant Professor Amity University Gurugram, Haryana Jasoda Sanasam Assistant Professor Maharishi Markandeshwar College of Nursing (MMCON) Maharishi Markandeshwar University (MMU) Ambala, Haryana

Malarkodi S Assistant Professor College of Nursing All India Institute of Medical Sciences Rishikesh, Uttarakhand Neha Saini Assistant Professor Galgotias University Greater Noida, Uttar Pradesh Nochovono Tase Principal College of Nursing North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS) Shillong, Meghalaya Parvinder Kaur Ex-Assistant Professor Maharishi Markandeshwar College of Nursing (MMCON) Maharishi Markandeshwar University (MMU) Ambala, Haryana Poonam Joshi Principal cum Professor College of Nursing All India Institute of Medical Sciences Kalyani, West Bengal Preeti Sahi Former Assistant Professor Maharishi Markandeshwar College of Nursing Mullana, Ambala, Haryana

Jeena Pradeep Senior Nursing Officer CNE Facilitator Kalawati Saran Children’s Hospital (KSCH) New Delhi

Prerna Sharma Clinical Instructor Florence Nightingale College of Nursing Guru Teg Bahadur Hospital New Delhi

Jeeva S Assistant Professor College of Nursing NIMHANS, Karnataka

Rajathisakthivel Vice Principal Hindu Mission College of Nursing Chennai, Tamil Nadu

Lilly Podder Associate Professor College of Nursing All India Institute of Medical Sciences Bhopal, Madhya Pradesh

Shilpi Sarkar Tutor Jamia Hamdard New Delhi

Contributors and Reviewers names are arranged in alphabetical order

Textbook of Pediatric Nursing

viii Susy Sarah John Senior Tutor College of Nursing Lady Hardinge Medical College and Smt Sucheta Kripalani Hospital, New Delhi

Yogesh Kumar Professor cum Principal Maharishi Markandeshwar Institute of Nursing Maharishi Markandeshwar (DU) Mullana, Ambala, Haryana

Reviewers Aruna Shastri (Pediatric Nursing) MSc (N) Nursing Officer Dr Baba Saheb Ambedkar Hospital Rohini, New Delhi

Hitesh Gautam (Pediatric Nursing) MSc (N) Principal GL Saini Memorial College of Nursing Jaipur, Rajasthan

Bhupendra Jain

Jacqueline Mary Jacob Professor cum Vice Principal Woodlands College of Nursing West Bengal

(Pediatric Nursing) MSc (N) HOD Rawat Nursing College Jaipur, Rajasthan Cecil C Khakha Medical Commissioner West Zone, ESIC Regional Office Ahmedabad, Gujarat Dhirendar Singh (Pediatric Nursing) PhD (N) Associate Professor Mata Gujri College of Nursing Mata Gujri University Kishanganji, Bihar

Jeya Vanitha A (Pediatric Nursing) PhD (N) (Pursuing), MSc (N) Professor and Principal Kirti Institute of Nursing and Paramedical Sciences Robertsganj, Sonbhadra, Uttar Pradesh Jyoti (Pediatric Nursing) MSc (N), BSc (Hons.) (N) Nursing Officer Vardhman Mahavir Medical College (VMMC) and Safdarjung Hospital, New Delhi

Divya Paratp Singh Sisodiya (Pediatric Nursing) MSc (N) Assistant Professor Venkteshwar College of Nursing Sai Triupati College of Nursing Pacific Medical University Udaipur, Rajasthan

Kamble Asmita Laxman (Pediatric Nursing) MSc (N) Assistant Professor College of Nursing Indira Gandhi Institute of Medical Sciences (IGIMS) Patna, Bihar

Hansmukh Jain (Pediatric Nursing) PhD (Pursuing), MSc (Pediatric Nursing), BSc (N), RN, RM Assistant Professor Department of Nursing All India Institute of Medical Sciences Patna, Bihar

Karishma Mulla (Pediatric Nursing) Msc (N) Clinical Instructor Hirai Institute of Nursing Education Malwadi, Masur, Pune, Maharashtra

Hardeep Kaur (Pediatric Nursing) MSc (N) Assistant Professor ST College of Nursing and Medical Sciences Mehlanwali, Hoshiarpur, Punjab

Kousar ul Islam (Pediatric Nursing) MSc (N), BSc (N) Tutor Government Nursing College Baramulla, Jammu and Kashmir

Contributors and Reviewers names are arranged in alphabetical order

ix

Leena Singh (Pediatric Nursing) PhD (Pursuing), MSc (N), RN, RM Clinical Tutor Rajendra Institute of Medical Sciences (RIMS) College of Nursing Ranchi, Jharkhand Manisha Thakur (Pediatric Nursing) MSc (N) Nursing Tutor Bee Enn College of Nursing Chak Bhalwal, Jammu and Kashmir Mayur Kumar Yadav (Pediatric Nursing) MSc (N) Nursing Officer All India Institute of Medical Sciences Raipur, Chhattisgarh Mir Uzma Ashraf (Pediatric Nursing) PhD (N), MSc (N), BSc (N) Assistant Professor College of Nursing Government Medical College Baramulla, Jammu and Kashmir

Rahul Garde Improvement Advisor Nationwide Quality of Care Network New Delhi Ruchi Sharma (Pediatric Nursing) MSc (N) Nursing Officer Post Graduate Institute of Medical Education and Research Chandigarh Rupa Ashok Verma (Pediatric Nursing) PhD (N) Principal MKSSS Sitabai Nargundkar College of Nursing for Women Nagpur, Maharashtra Rupali Vijay Kamble (Pediatric Nursing) MSc (N) Assistant Professor Vijaysinh Mohite-Patil College of Nursing and Medical Research Institute Akluj, Solapur, Maharashtra Rupinder Deol (Pediatric Nursing) PhD (Scholar), MSc (Pediatric Nursing), BSc (N) Associate Professor College of Nursing All India Institute of Medical Sciences Rishikesh, Uttarakhand S Vasanthakumari Sundararajan PhD (N), MA (Child Care and Education), RN, RM Post Graduate Diploma in Educational Management and Supervision Certified Emotional Intelligence Specialist (CEIS) Associate Professor in Pediatric and Neonatal Nursing Institute of Health Sciences Wollega University, Ethiopia

Monika Christian (Pediatric Nursing) Associate Professor Chaudhari Institute of Nursing Gandhinagar, Gujarat Narendra Singh Rajput (Pediatric Nursing) MSc (N) Vice Principal Rajasthan College of Nursing Dausa, Rajasthan Parmees Kaur Lecturer College of Nursing Government Medical College and Hospital Chandigarh Purnima Sahoo (Pediatric Nursing) PhD (Scholar), MSc (N) Associate Professor Kalinga Institute of Nursing Sciences KIIT (DU), Bhubaneswar, Odisha

Safeena Beevi S S (Pediatric Nursing) PhD (Pursuing), MSc (N), RN, RM, GCP Associate Professor College of Nursing Aligarh Muslim University (AMU) Aligarh, Uttar Pradesh Sain Priya (Pediatric Nursing) MSc (N) Associate Professor (HOD Child Health Nursing Department) Bee Enn College of Nursing Chak Bhalwal, Jammu and Kashmir

Contributors and Reviewers names are arranged in alphabetical order

Contributors and Reviewers

Leena Pravil John (Pediatric Nursing) MSc (N), RN, RM Associate Professor cum Vice Principal Christian College of Nursing, SIHAS, SHUATS Prayagraj, Uttar Pradesh

Textbook of Pediatric Nursing

x Sanjna Kumari (Pediatric Nursing) MSc (N) Assistant Professor Sharda School of Nursing Sciences and Research Sharda University, Greater Nodia, Uttar Pradesh

Sonu Kumar Sharma (Pediatric Nursing) Assistant Professor Seedling School of Nursing Jaipur National University Jaipur, Rajasthan

Sara Tomy MSc (N) Lecturer MVP’s Samaj’s Institute of Nursing Education Adgaon, Nashik, Maharashtra

Sunil Kumar Dadheech (Pediatric Nursing) PhD (Pursuing), MSc (N) Principal Mewar BSc Nursing College Udaipur, Rajasthan

Seena P Nair (Pediatric Nursing) MSc (N) Lecturer/Nursing Tutor Government College of Nurisng Jodhpur, Rajasthan Shaila Nazir Tutor Dolphin Institute of Medical Sciences and Technology Pulwama, Jammu and Kashmir Shalini Violet (Pediatric Nursing) MSc (N) Associate Professor Vijaya Raje College of Nursing Jodhpur, Rajasthan Shivcharan Singh Gandhar Professor cum Principal MIT’s Vishwaraj Institute of Nursing (MAEER) Loni Kalbhor, Pune, Maharashtra Shrikant Desai (Pediatric Nursing) Msc (N) Assistant Nursing Superintendent All India Institute of Medical Sciences Rishikesh, Uttarakhand Simran Shaikh (Pediatric Nursing) MSc (N) Nursing Tutor Sandra Shroff ROFEL College of Nursing Vapi, Gujarat Smruti Pragyan Sahoo (Pediatric Nursing) MSc (N) Tutor Kalinga Institute of Nursing Sciences KIIT (DU), Bhubaneswar, Odisha

Tarika Sharma Assistant Professor College of Nursing Institute of Liver and Biliary Sciences (ILBS) New Delhi Ulfat Amin (Pediatric Nursing) MSc (N), PB BSc (N), GNM Faculty Syed Mantaqui Memorial College of Nursing and Medical Technology (SMMCNMT) Islamic University of Science and Technology (IUST) Pulwama, Jammu and Kashmir Upendra Veerwal (Pediatric Nursing) MSc (N) Assistant Professor Geetanjali College of Nursing Udaipur, Rajasthan Vibha Kumari Ameta (Pediatric Nursing) MSc (N) Associate Professor Udaipur College of Nursing Udaipur, Rajasthan Vipin Vageriya (Pediatric Nursing) MSc (N) Assistant Professor Manikaka Topawala Institute of Nursing CHARUSAT Anand, Gujarat Wilfreena Lovelyn Pinto (Pediatric Nursing) MSc (N) Associate Professor Alva’s College of Nursing  Alva’s Health Centre Moodabidri, Mudbidri, Karnataka

Contributors and Reviewers names are arranged in alphabetical order

Preface The health problems in developing countries are quite challenging and require a comprehensive approach to child health problems by all health professionals including nurses. Nurses and health care professionals need to be trained in identifying and catering to the needs of children. Clinical and practical expertise of a pediatric nurse is highly demanding in handling child health problems. Therefore, it is essential for the pediatric nurses to enrich their clinical and theoretical skills to contribute towards a healthy childhood. This textbook is designed for undergraduate students as per the Revised INC Syllabus. This book has been designed and presented as per the curriculum requirements. This book addresses the domains of child development—emotional, social, physical, cognitive, language, and creative, which are readily observable and nursing considerations for developing clear concepts of growth and development in a systematic way. All the major disease conditions have been covered extensively with brief reference of rare diseases along with comprehensive nursing processes for the diseases. Throughout the book extensive use of figures, illustrations, tables have been used to make the concept clear from a student point of view. Latest treatment protocols and management logarithms have been covered wherever needed to give an edge to the study. The Units of the book have been organized systematically according to the Revised INC syllabus to explore and validate current knowledge. This book is studded with plenty of features and is a perfect amalgamation of theoretical as well as practical/ clinical aspects. The content of the book has been designed in the manner that students will correlate theoretical knowledge with their clinical practice. We are pretty sure that this book will surely be useful for nursing students.

Jyoti Sarin Smriti Arora

xiii

Acknowledgments We express our sincere thanks to the God Almighty, for giving an idea to accomplish this book. We express our heartiest gratitude to our family members for their unconditional support and motivation to fulfil this commitment. We would like to thank Mr Satish Kumar Jain (Chairman) and Mr Varun Jain (Managing Director), M/s CBS Publishers and Distributors Pvt Ltd for providing us the platform in bringing out the book. We have no words to describe the role, efforts, inputs and initiatives undertaken by Mr Bhupesh Aarora, Sr. Vice President – Publishing and Marketing (Health Sciences Division) for helping and motivating us. We sincerely thank the entire CBS team for bringing out the book with utmost care and attractive presentation. We would like to thank Ms Nitasha Arora (Publishing Head and Content Strategist – Medical and Nursing), Ms Daljeet Kaur (Assistant Publishing Manager) and Dr Anju Dhir (Product Manager and Medical Development Editor) for their editorial support. We would also extend our thanks to Mr Shivendu Bhushan Pandey (Sr. Manager and Team Lead), Mr Ashutosh Pathak (Sr. Proofreader cum Team Coordinator) and all the production team members for devoting laborious hours in designing and typesetting the book.

From Publisher’s Desk Dear Reader, Nursing Education has a rich history, often characterized by traditional teaching techniques that have evolved over time. Primarily, teaching took place within classroom settings. Lectures, textbooks, and clinical rotations were the core teaching tools; and students majorly relied on textbooks by local or foreign publishers for quality education. However, today, technology has completely transformed the field of nursing education, making it an integral part of the curriculum. It has evolved to include a range of technological tools that enhance the learning experience and better prepare students for clinical practice. As publishers, we’ve been contributing to the field of Medical Science, Nursing and Allied Sciences and earned the trust of many. By supporting Indian authors, coupled with nursing webinars and conferences, we have paved an easier path for aspiring nurses, empowering them to excel in national and state level exams. With this, we’re not only enhancing the quality of patient care but also enabling future nurses to adapt to new challenges and innovations in the rapidly evolving world of healthcare. Following the ideology of Bringing learning to people instead of people going for learning, so far, we’ve been doing our part by: • • • •

Developing quality content by qualified and well-versed authors Building a strong community of faculty and students Introducing a smart approach with Digital/Hybrid Books, and Offering simulation Nursing Procedures, etc.

Innovative teaching methodologies, such as modern-age Phygital Books, have sparked the interest of the Next-Gen students in pursuing advanced education. The enhancement of educational standards through Omnipresent Knowledge Sharing Platforms has further facilitated learning, bridging the gap between doctors and nurses. At Nursing Next Live, a sister concern of CBS Publishers & Distributors, we have long recognized the immense potential within the nursing field. Our journey in innovating nursing education has allowed us to make substantial and meaningful contributions. With the vision of strengthening learning at every stage, we have introduced several plans that cater to the specific needs of the students, including but not limited to Plan UG for undergraduates, Plan MSc for postgraduate aspirants, Plan FDP for upskilling faculties, SDL for integrated learning and Plan NP for bridging the gap between theoretical & practical learning. Additionally, we have successfully completed seven series of our Target High Book in a very short period, setting a milestone in the education industry. We have been able to achieve all this just with the sole vision of laying the foundation of diversified knowledge for all. With the rise of a new generation of educated, tech-savvy individuals, we anticipate even more remarkable advancements in the coming years. We take immense pride in our achievements and eagerly look forward to the future, brimming with new opportunities for innovation, growth and collaborations with experienced minds such as yourself who can contribute to our mission as Authors, Reviewers and/or Faculties. Together, let’s foster a generation of nurses who are confident, competent, and prepared to succeed in a technology-driven healthcare system.

Mr Bhupesh Aarora

(Sr Vice President – Publishing & Marketing) [email protected]| +91 95553 53330

Special Features of the Book Learning Objectives

Learning Objectives given in the beginning of each Unit will enable the students to know what the students will be able to learn, after reading it.

At the end of this unit, the students will be able to: Â Explain the modern concept of child care. Â Describe national policy, programs and legislation in relation to child health and welfare. Â Discuss preventive pediatrics. Â List major causes of death during infancy, early and late childhood.

Chapter Outline  Introduction

 Historical Perspectives on Child Care Practices  Health Care Delivery System in India

 National Policies, Legislation and Agencies

Related to Child Welfare

Chapter Outline will summarize what the students will learn after studying the chapter.

 National Health Programs Related to Children  Internationally Accepted Rights of the Child  Changing Trends in Child Health

Table 2.4: Causes of infant morbidity and mortality

Numerous Tables summarizing important information have been included wherever necessary, for quick recall.

During neonatal period (0–4 weeks)

During postneonatal period (1–12 months)

Low birth weight Acute respiratory infections Tetanus Sepsis Birth asphyxia

Diarrheal diseases Acute respiratory infections Measles Pneumonia Malnutrition

TIPS for Successful Complementary Feeding • Always sit near baby while he or she is feeding so that baby does not choke. • Never force feed the baby. • Make sure that the food has the right temperature. Do not make it too hot. • If baby refuses to eat a particular type of food, consider backing off and offer it later on. • Offer baby a wide range of foods so that he or she gets used to different flavors.

Important facts from nursing considerations point of view have been covered under TIPS boxes.

Textbook of Pediatric Nursing

xx

Important concepts and topics have been supplemented with numerous Figures/Illustrations/Tables for easy understanding.

Figure 4.3: Facial expressions of pain in the infant

Must Know • On the first day, the fluid requirements range from 60–80 mL/ kg, the difference between the two categories being 20 mL • The daily increment in all groups is around 15 mL/kg till day 7. • Extra 20–30 mL/kg fluid should be added for infants nursed naked under a radiant warmer. For those receiving phototherapy add extra 15 mL/kg fluid. • These are general guidelines; fluid therapy of each baby should be individualized.

Must Know facts are covered throughout the book from clinical practice point of view.

Summary

Each and every chapter ends with summarized oneliner for quick glance of the chapter.

The concept of child care has progressed immensely from mother-centric care to family-centered care and promotion of vaccinations. There have been many recent changes in health care delivery systems including health and wellness centers; the laws, health programs, policies and schemes specific related to children. Focus on preventive aspects and evidence-based care is emphasized.

Assess Yourself 1. List the internationally accepted rights of child. 2. Discuss the changing trends in child health nursing. 3. Explain the latest initiatives of government to achieve goals related to child health. 4. Write full forms of: • JSY, JSSY, NSSK, F-IMNCI, UNICEF, CRY, ASHA, ICDS, SNCU, FRU • RKSK, CSSM, RMNCH A, RBSK, POCSO

Important subjective and objective questions under Assess Yourself have been added at the end of every chapter to help the students assess their learning.

Syllabus CHILD HEALTH NURSING-I Placement: V Semester

Theory: 3 Credit (60 Hours)

Practicum: Lab/Skill Lab: 1 Credit (40 hours)

Clinical: 2 Credits (160 hours)

Course Content Unit

Time (Hrs)

I

10 (T) 10 (L)

Learning Outcomes

T– Theory, L–Lab Content

Teaching/ Learning Activities

Assessment Methods

Explain the modern concept of child-care

Introduction: Modern Concepts of Child-care • Lecture discussion • Short answer • Historical development of child health • Demonstration of • Objective type • Philosophy and modern concept of child-care common pediatric • Assessment • Cultural and religious considerations in childof skills with procedures care checklist

Describe National policy, programs and legislation in relation to child health and welfare

• National policy and legislations in relation to child health and welfare • National programs and agencies related to welfare services to the children • Internationally accepted rights of the child • Changing trends in hospital care, preventive, promotive and curative aspect of child health

Describe role of preventive pediatrics

• Preventive pediatrics: ƒ Concept ƒ Immunization ƒ Immunization programs and cold chain. ƒ Care of under-five and under-five clinics/wellbaby clinics ƒ Preventive measures towards accidents

List major causes of • Child morbidity and mortality rates death during infancy, • Difference between an adult and child which early and late childhood affect response to illness Differentiate between ƒ Physiological an adult and child in ƒ Psychological terms of illness and ƒ Social response ƒ Immunological Describe the major functions and role of the pediatric nurse in caring for a hospitalized child.

• Hospital environment for sick child • Impact of hospitalization on the child and family • Communication techniques for children • Grief and bereavement

Describe the principles of child health nursing and perform child health nursing procedures

• The role of a child health nurse in caring for a hospitalized child • Principles of pre- and postoperative care of infants and children Child Health Nursing procedures: • Administration of medication: Oral, I/M, and I/V • Calculation of fluid requirement • Application of restraints • Assessment of pain in children ƒ FACES pain rating scale ƒ FLACC scale ƒ Numerical scale Contd…

Textbook of Pediatric Nursing

xxii Unit

Time (Hrs)

II

12 (T)

Learning Outcomes

Content

Teaching/ Learning Activities

Assessment Methods

Describe the normal growth and development of children at different ages

The Healthy Child • Definition and principles of growth and development • Factors affecting growth and development

• Lecture discussion • Demonstration • Developmental

• Short answer • Objective type • Assessment of

• Identify the needs of children at different ages and provide parental guidance • Identify the nutritional needs of children at different ages and ways of meeting needs

• Growth and development from birth to adolescence • Growth and developmental theories (Freud, Erickson, Jean Piaget, Kohlberg) • The needs of normal children through the stages of developmental and parental guidance

• Observation study

• Short answer • Objective type • Assessment of

Identify the role of play for normal and sick children

• Nutritional needs of children and infants ƒ Breastfeeding ƒ Exclusive breastfeeding ƒ Supplementary/artificial feeding and weaning • Baby friendly hospital concept • Types and value of play and selection of play material

• Clinical practice/

study of infant and children

of normal and sick child • Field visit to Anganwadi, child guidance clinic • Videos on breastfeeding

field visits and developmental study reports

field visits and developmental study reports

field

III

15 (T) 20 (L)

• Provide care to normal and high-risk neonates • Perform neonatal resuscitation • Recognize and manage common neonatal problems

Nursing Care of Neonate • Appraisal of newborn • Nursing care of a normal newborn/essential newborn care • Neonatal resuscitation • Nursing management of low birth weight baby • Kangaroo mother care • Nursing management of common neonatal disorder ƒ Hyperbilirubinemia ƒ Hypothermia ƒ Hyperthermia ƒ Metabolic disorder ƒ Neonatal infections ƒ Neonatal seizures ƒ Respiratory distress syndrome ƒ Retinopathy of prematurity • Organization of neonatal care unit • Neonatal equipment

• Modular-based teaching: ENBC and FBNC module (oral drills, videos, self-evaluation exercises) • Workshop on neonatal resuscitation: NRP module • Demonstration • Practice session • Clinical practice • Lecture discussion

• OSCE • Short answer • Objective type

IV

10 (T) 5 (L)

Apply principles and strategies of IMNCI

Integrated Management of Neonatal and Childhood Illnesses

Modular based teaching: IMNCI module • Clinical practice/ field

• OSCE

V

8 (T)

Describe the etiology, pathophysiology, clinical manifestation and nursing management of children with disorders of respiratory, and endocrine system

Nursing Management in Common Childhood Diseases Respiratory system • Identification and nursing management of congenital malformations • Congenital disorders: Tracheoesophageal fistula, diaphragmatic hernia

• • • •

• Short answer • Objective type • Assessment of skills with checklist

Lecture discussion Demonstration Practice session Clinical practice

Contd…

xxiii Time (Hrs)

Learning Outcomes

Content

Teaching/ Learning Activities

Assessment Methods

• Others: Acute nasopharyngitis, tonsillitis, croup, bronchitis, bronchiolitis, pneumonia, asthma Endocrine system: • Juvenile diabetes mellitus, Hypothyroidism VI

5 (T) 5 (L)

Develop ability to meet Childhood Emergencies child-hood emergencies • Accidents – causes and prevention, poisoning, foreign bodies, hemorrhage, burns and and perform child CPR drowning • PLS (AHA guidelines)

• • • •

Lecture Discussion Demonstration PLS module/ workshop

• OSCE

CHILD HEALTH NURSING-II Placement: VI Semester

Theory: 2 Credit (40 Hours)

Practicum: Clinical: 1 Credit (80 hours)

Course Content Unit

Time (Hrs)

Learning Outcomes

I

20 (T)

Describe the etiology, pathophysiology, clinical manifestation and nursing management of children with disorders of cardiovascular, gastrointestinal, genitourinary, and nervous system

T– Theory Content

Teaching/ Learning Activities

Cardiovascular System • Lecture cum • Identification and nursing management of discussion congenital malformations • Demonstration and • Congenital heart diseases: Cyanotic and practice session Acyanotic (ASD, VSD, PDA, TOF) • Others: Rheumatic fever and rheumatic heart disease, congestive cardiac failure • Hematological conditions: a. Congenital: Hemophilia, thalassemia b. Others: Anemia, leukemia, idiopathic thrombocytopenic purpura, Hodgkins and non-Hodgkins lymphoma Gastrointestinal System • Identification and nursing management of congenital malformations. • Congenital: Cleft lip, cleft palate, congenital hypertrophic pyloric stenosis, Hirschsprung disease (megacolon), anorectal malformation, malabsorption syndrome, abdominal wall defects, hernia • Others: Gastroenteritis, diarrhea, vomiting, protein energy malnutrition, intestinal obstruction, hepatic diseases, intestinal parasites Genitourinary Urinary System • Identification and nursing management of congenital malformations. • Congenital: Wilms’, tumor, extropy of bladder, hypospadias, epispadias, obstructive uropathy • Others: Nephrotic syndrome, acute glomerulonephritis, renal failure

Assessment Methods • Short answer • Objective type • Assessment

of skills with checklist

Contd…

Syllabus

Unit

Textbook of Pediatric Nursing

xxiv

Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/ Learning Activities

Assessment Methods

Nervous System • Identification and nursing management of congenital malformations a. Congenital: Spina bifida, hydrocephalous. b. Others: Meningitis, encephalitis, convulsive disorders (convulsions and seizures), cerebral palsy head injury II

III

10 (T)

10 (T)

Orthopedic Disorders • Club foot • Hip dislocation and • Fracture Disorder of Eye, Ear and Skin • Refractory errors • Otitis media and • Atopic dermatitis Communicable diseases in children, their identification/diagnosis, nursing management in hospital, in home, control and prevention: • Tuberculosis • Diphtheria • Tetanus • Pertussis • Poliomyelitis • Measles • Mumps, and • Chickenpox • HIV/AIDS • Dengue fever • COVID-19

• Lecture cum

Management of Behavior and Social Problems in Children • Child guidance clinic • Common behavior disorders in children and management ƒ Enuresis and encopresis • Identify the social and ƒ Nervousness welfare services for ƒ Nail biting challenged children ƒ Thumb sucking ƒ Temper tantrum ƒ Stealing ƒ Aggressiveness ƒ Juvenile delinquency ƒ School phobia ƒ Learning disability • Psychiatric disorders in children and management ƒ Childhood schizophrenia ƒ Childhood depression ƒ Conversion reaction ƒ Post-traumatic stress disorder ƒ Autistic spectrum disorders

• Lecture cum

Describe the etiology, pathophysiology, clinical manifestation and nursing management of children with orthopedic disorders, eye, ear and skin disorders

• Describe the management of children with behavioral and social problems

discussion • Demonstration • Practice session • Clinical practice

discussion • Field visits to child guidance clinics, school for mentally and physically, socially challenged

• Short answer • Objective type • Assessment

of skills with checklist

• Short answer • Objective type • Assessment of

field reports

Contd…

xxv Time (Hrs)

Learning Outcomes

Content

• Eating disorder in children and management ƒ Obesity ƒ Anorexia nervosa ƒ Bulimia • Management of challenged children ƒ Mentally ƒ Physically ƒ Socially ƒ Child abuse ƒ Substance abuse • Welfare services for challenged children in India

Teaching/ Learning Activities

Assessment Methods

Syllabus

Unit

Contents About the Authors.................................................................................................................................................................................................... v Contributors and Reviewers .................................................................................................................................................................................. vii Preface ........................................................................................................................................................................................................................ xi Acknowledgments ................................................................................................................................................................................................... xiii Special Features of the Book ................................................................................................................................................................................. xix Syllabus ...................................................................................................................................................................................................................... xxi

UNIT I  INTRODUCTION: MODERN CONCEPTS OF CHILD CARE Chapter 1 Child Care Concepts z z z z z z z

Introduction.................................................................................................................................................................................... 3 Historical Perspectives on Child Care Practices................................................................................................................. 3 Health Care Delivery System in India..................................................................................................................................... 5 National Policies, Legislation and Agencies Related to Child Welfare....................................................................... 6 National Health Programs Related to Children.................................................................................................................. 10 Internationally Accepted Rights of the Child...................................................................................................................... 16 Changing Trends in Child Health ........................................................................................................................................... 17

Chapter 2 Preventive Pediatrics z z z z z z z

z z z z z z z z

z z z z

28–35

Differences between Children and Adults........................................................................................................................... 28 Hospital Environment for a Sick Child................................................................................................................................... 29 Impact of Hospitalization on Child......................................................................................................................................... 30 Nursing Care of a Hospitalized Child..................................................................................................................................... 32 Effects of Hospitalization on Family....................................................................................................................................... 33 Grief and Bereavement............................................................................................................................................................... 33 Role of a Child Health Nurse..................................................................................................................................................... 33 Ethics in Pediatric Nursing......................................................................................................................................................... 34 Principles of Pre- and Postoperative Care for Children................................................................................................... 34

Chapter 4 Child Health Nursing Procedures z

18–27

Introduction ................................................................................................................................................................................... 18 Immunization ................................................................................................................................................................................ 18 Vaccines ........................................................................................................................................................................................... 19 Under Five-Clinics/Well Baby Clinics...................................................................................................................................... 21 Child Morbidity and Mortality.................................................................................................................................................. 22 Infant Morbidity and Mortality................................................................................................................................................ 23 Accidents in Young Children..................................................................................................................................................... 25

Chapter 3 Hospitalized Child z

3–17

36–44

Introduction ................................................................................................................................................................................... 36 Administration of Medication: Oral........................................................................................................................................ 36 Administration of Medication: IM........................................................................................................................................... 37 Calculation of Fluid Requirement .......................................................................................................................................... 38 Calculation of Drop Rate ........................................................................................................................................................... 38

Textbook of Pediatric Nursing

xxviii z z

Application of Restraints ........................................................................................................................................................... 38 Pain Assessment in Children..................................................................................................................................................... 39

UNIT II  THE HEALTHY CHILD Chapter 5 Development Theories and Physical Examination z z z z z z z

Introduction.................................................................................................................................................................................... 47 Principles and Factors Affecting Growth and Development........................................................................................ 47 Developmental Theories............................................................................................................................................................ 48 Development Assessment......................................................................................................................................................... 53 Pediatric History and Physical Examination........................................................................................................................ 60 Newborn Examination ............................................................................................................................................................... 70 Newborn Reflexes ........................................................................................................................................................................ 77

Chapter 6 Growth and Development at Various Stages z z z z z z z z z z

47–79

80–96

Introduction.................................................................................................................................................................................... 80 Growth and Development of Infants..................................................................................................................................... 80 Growth and Development of Toddlers (1–3 Years)........................................................................................................... 82 Growth and Development of Preschoolers (3–6 Years).................................................................................................. 84 Growth and Development of School Age (6–12 Years)................................................................................................... 85 Growth and Development in Adolescents (12–18 Years)............................................................................................... 87 Nutritional Needs of Infants and Children........................................................................................................................... 89 Baby-Friendly Hospital Initiative............................................................................................................................................. 94 Failure to Thrive............................................................................................................................................................................. 94 Types and Advantages of Play................................................................................................................................................. 95

UNIT III  NURSING CARE OF NEONATE Chapter 7 Normal Newborn z z z z z z

Introduction.................................................................................................................................................................................... 99 Neonatal Resuscitation............................................................................................................................................................... 99 Birth Injuries................................................................................................................................................................................... 102 Essential Newborn Care.............................................................................................................................................................. 104 Facility-Based Newborn Care.................................................................................................................................................... 105 Facility-Based Integrated Management of Neonatal and Childhood Illness........................................................... 107

Chapter 8 Low Birth Weight Baby z z z z z z z

z z

109–119

Introduction.................................................................................................................................................................................... 109 Low Birth Weight (LBW) Baby.................................................................................................................................................. 109 Management of LBW Babies.................................................................................................................................................... 111 Kangaroo Mother Care................................................................................................................................................................ 114 Organization of Neonatal Unit................................................................................................................................................. 116 Neonatal Transport....................................................................................................................................................................... 117 Neonatal Equipment................................................................................................................................................................... 118

Chapter 9 Management of Neonatal Conditions z

99–108

120–137

Introduction ................................................................................................................................................................................... 120 Management of Neonatal Conditions................................................................................................................................... 120 Respiratory Distress Syndrome................................................................................................................................................ 123

xxix

z z z z z z

Neonatal Sepsis............................................................................................................................................................................. 124 Neonatal Jaundice........................................................................................................................................................................ 127 Neonatal Seizures......................................................................................................................................................................... 131 Retinopathy of Prematurity....................................................................................................................................................... 132 Neonatal Hypoglycemia............................................................................................................................................................. 133 Neonatal Shock.............................................................................................................................................................................. 133 Emergency Triage Assessment and Treatment.................................................................................................................. 135

UNIT IV  INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS (IMNCI) Chapter 10 Management of Sick Young Infants—Up to 2 Months z z z z z

Introduction.................................................................................................................................................................................... 141 Evidence-Based Syndromic Approach.................................................................................................................................. 141 Principles of Integrated Care.................................................................................................................................................... 142 IMNCI Case Management Process.......................................................................................................................................... 142 Treat the Young Infant and Counsel the Mother............................................................................................................... 148

Chapter 11 Management of Sick Children—2 Months to 5 Years z z

141–152

153–169

Introduction.................................................................................................................................................................................... 153 Assessment and Management of Sick Children................................................................................................................ 153

UNIT V  COMMON CHILDHOOD DISEASES Chapter 12 Respiratory Disorders

173–188

Introduction ................................................................................................................................................................................... 173 Upper Respiratory Tract Infection (URTI).............................................................................................................................. 173 z Lower Respiratory Tract Infections (LRTI)............................................................................................................................. 174 z Tuberculosis.................................................................................................................................................................................... 177 z Bronchial Asthma.......................................................................................................................................................................... 179 z Cystic Fibrosis................................................................................................................................................................................. 181 Common Respiratory Surgical Conditions............................................................................................................................... 182 z Choanal Atresia.............................................................................................................................................................................. 182 z Congenital Diaphragmatic Hernia (CDH)............................................................................................................................. 183 z Esophageal Atresia with Tracheoesophageal Fistula....................................................................................................... 185 z z

Chapter 13 Endocrine Disorders z z z z z z z z

189–203

Introduction.................................................................................................................................................................................... 189 Functions of Endocrine System............................................................................................................................................... 189 Causes of Endocrine Disorders................................................................................................................................................ 189 Antidiuretic Hormone (ADH) Disorders................................................................................................................................ 189 Adrenal Disorders......................................................................................................................................................................... 191 Growth Hormone Insufficiency............................................................................................................................................... 193 Disorders of Pancreas.................................................................................................................................................................. 196 Disorders of Thyroid Gland........................................................................................................................................................ 200

UNIT VI  CHILDHOOD EMERGENCIES Chapter 14 Management of Different Emergencies in Children z

207–219

Introduction ................................................................................................................................................................................... 207

Contents

z

Textbook of Pediatric Nursing

xxx Managing Common Childhood Emergencies......................................................................................................................... 207 z Foreign Body Airway Obstruction (FBAO, Choking)......................................................................................................... 207 z SnakeBite......................................................................................................................................................................................... 208 z Dog Bite............................................................................................................................................................................................ 209 z Drowning......................................................................................................................................................................................... 209 z Poisoning......................................................................................................................................................................................... 210 z Hemorrhage................................................................................................................................................................................... 211 z Burns.................................................................................................................................................................................................. 212 z Pediatric Basic Life Support....................................................................................................................................................... 217

UNIT VII  DISEASE CONDITIONS–I Chapter 15 Cardiovascular Disorders z z z z z z z z

Introduction.................................................................................................................................................................................... 223 Related Anatomy of Heart......................................................................................................................................................... 223 Congenital Heart Disease.......................................................................................................................................................... 225 Nursing Care of a Child with Cardiac Surgery.................................................................................................................... 234 Congestive Heart Failure (CHF)................................................................................................................................................ 235 Rheumatic Fever........................................................................................................................................................................... 237 Infective Endocarditis.................................................................................................................................................................. 238 Acquired Heart Disease.............................................................................................................................................................. 239

Chapter 16 Hematological Disorders z z z z z z z z

z z z z z z z z z z z z z z

241–255

Introduction ................................................................................................................................................................................... 241 Blood................................................................................................................................................................................................. 241 Classification of Blood Disorders............................................................................................................................................. 241 Anemia............................................................................................................................................................................................. 241 Hemophilia...................................................................................................................................................................................... 250 Thrombocytopenia...................................................................................................................................................................... 251 Idiopathic Thrombocytopenic Purpura................................................................................................................................ 252 Leukemia.......................................................................................................................................................................................... 253

Chapter 17 Gastrointestinal Disorders z

223–240

256–279

Introduction.................................................................................................................................................................................... 256 Cleft Lip and Palate...................................................................................................................................................................... 256 Gastroesophageal Reflux Disease........................................................................................................................................... 258 Hypertrophic Pyloric Stenosis.................................................................................................................................................. 259 Choledochal Cyst.......................................................................................................................................................................... 261 Extrahepatic Biliary Atresia (EHBA)........................................................................................................................................ 264 Intestinal Disorders...................................................................................................................................................................... 264 Abdominal Wall Defects............................................................................................................................................................. 268 Anorectal Malformation............................................................................................................................................................. 271 Hepatitis .......................................................................................................................................................................................... 274 Lactose Intolerance...................................................................................................................................................................... 276 Malabsorption Syndrome.......................................................................................................................................................... 276 Celiac Disease................................................................................................................................................................................. 277 Appendicitis.................................................................................................................................................................................... 277 Worm Infestation.......................................................................................................................................................................... 278

xxxi

z z z z

280–292

Introduction ................................................................................................................................................................................... 280 Malnutrition.................................................................................................................................................................................... 280 Eating Disorders............................................................................................................................................................................ 287 Vitamin Deficiency Disorders................................................................................................................................................... 290

Chapter 19 Genitourinary Disorders

293–309

Introduction.................................................................................................................................................................................... 293 z Urinary Tract Infection................................................................................................................................................................. 293 z Nephrotic Syndrome................................................................................................................................................................... 294 z Acute Glomerulonephritis......................................................................................................................................................... 297 z Hemolytic Uremic Syndrome................................................................................................................................................... 298 z Acute Renal Failure....................................................................................................................................................................... 298 z Chronic Kidney Disease.............................................................................................................................................................. 300 Surgical Genitourinary Disorders................................................................................................................................................. 302 z Hypospadias and Epispadias.................................................................................................................................................... 302 z Bladder Exstrophy......................................................................................................................................................................... 303 z Cryptorchidism/Undescended Testicle................................................................................................................................. 304 z Wilms’ Tumor (Nephroblastoma)............................................................................................................................................ 305 z Ureteropelvic Junction Obstruction...................................................................................................................................... 307 z Vesicoureteral Reflux................................................................................................................................................................... 307 z

Chapter 20 Neurological Disorders z z z z z z z z z z z

310–333

Introduction.................................................................................................................................................................................... 310 Meningitis........................................................................................................................................................................................ 310 Seizure Disorders.......................................................................................................................................................................... 314 Cerebral Palsy................................................................................................................................................................................. 318 Reye’s Syndrome........................................................................................................................................................................... 320 Encephalitis..................................................................................................................................................................................... 321 Traumatic Brain Injury................................................................................................................................................................. 322 Hydrocephalus............................................................................................................................................................................... 324 Spina Bifida..................................................................................................................................................................................... 328 Neuroblastoma.............................................................................................................................................................................. 330 Brain Tumors................................................................................................................................................................................... 331

UNIT VIII  DISEASE CONDITIONS–II Chapter 21 Musculoskeletal Disorders z z z z z z z z z

337–353

Introduction.................................................................................................................................................................................... 337 Bowleg and Knock-Knee............................................................................................................................................................ 337 Clubfoot........................................................................................................................................................................................... 338 Fracture............................................................................................................................................................................................ 339 Dislocation of Hip......................................................................................................................................................................... 341 Juvenile Rheumatoid Arthritis................................................................................................................................................. 343 Duchenne’s Muscular Dystrophy............................................................................................................................................ 344 Osteogenesis Imperfecta........................................................................................................................................................... 344 Scoliosis............................................................................................................................................................................................ 345

Contents

Chapter 18 Nutritional Disorders

Textbook of Pediatric Nursing

xxxii z z

Myasthenia Gravis........................................................................................................................................................................ 348 Therapeutic Techniques for Musculoskeletal Disorders................................................................................................. 348

Chapter 22 Disorders of Skin, Eye and Ear z z z

Skin Disorders................................................................................................................................................................................ 354 Eye Disorders.................................................................................................................................................................................. 358 Ear Disorders................................................................................................................................................................................... 361

Chapter 23 Communicable Diseases z z z z

z z z z z z

z z

376–383

Introduction.................................................................................................................................................................................... 376 Single-Gene Disorders................................................................................................................................................................ 376 Non-Mendelian Inheritance...................................................................................................................................................... 379 Chromosomal Abnormalities................................................................................................................................................... 379 Multifactorial and Polygenic Disorders................................................................................................................................. 381 Nursing Care of Children with Chromosomal Aberrations............................................................................................ 381 Genetic Testing and Counseling.............................................................................................................................................. 381

Chapter 25 Inborn Errors of Metabolism z

364–375

Common Communicable Diseases........................................................................................................................................ 364 HIV/AIDS.......................................................................................................................................................................................... 365 Dengue Fever................................................................................................................................................................................. 370 COVID-19 ........................................................................................................................................................................................ 371

Chapter 24 Genetic Disorders z

354–363

384–386

Introduction ................................................................................................................................................................................... 384 Galactosemia.................................................................................................................................................................................. 384 Phenylketonuria............................................................................................................................................................................ 385

UNIT IX  BEHAVIORAL AND SOCIAL PROBLEMS IN CHILDREN Chapter 26 Child with Behavioral Problems z z z z z

Introduction.................................................................................................................................................................................... 389 Causes of Behavioral Disorders................................................................................................................................................ 389 Types of Behavioral Disorders.................................................................................................................................................. 389 Basic Approach to Child with any Behavioral Disorder................................................................................................... 402 Nursing Responsibilities in Management of Behavioral Problems of Children..................................................... 402

Chapter 27 Challenged Child z z z z

389–402

403–412

Challenged (Handicapped) Children..................................................................................................................................... 403 Child Abuse/Maltreatment/Battered Child Syndrome.................................................................................................... 406 Welfare Services for Challenged Children In India............................................................................................................ 409 Child Guidance Clinic.................................................................................................................................................................. 411

Multiple Choice Questions........................................................................................................................................................................................ 413 Case-Based Scenarios................................................................................................................................................................................................. 425 Index................................................................................................................................................................................................................................ 427

Unit

I

Introduction: Modern Concepts of Child Care Learning Objectives At the end of this unit, the students will be able to: Â Explain the modern concept of child care. Â Describe national policy, programs and legislation in relation to child health and welfare. Â Discuss preventive pediatrics. Â List major causes of death during infancy, early and late childhood.

Unit Outline Chapter 1  Child Care Concepts Chapter 2  Preventive Pediatrics Chapter 3  Hospitalized Child Chapter 4  Child Health Nursing Procedures

 Differentiate between an adult and child in terms

of illness and response.

 Describe the role of pediatric nurse in caring for a

hospitalized child. Â Describe the principles of child health nursing. Â Perform child health nursing procedures.

Chapter

1

Child Care Concepts Chapter Outline  Introduction

 National Health Programs Related to Children

 Health Care Delivery System in India

 Changing Trends in Child Health

 Historical Perspectives on Child Care Practices  National Policies, Legislation and Agencies

 Internationally Accepted Rights of the Child

Related to Child Welfare

INTRODUCTION Children are the endowment and divine gift to human beings whose innocent smiles and hugs make this world more beautiful. There are considerable differences between adult and children in many aspects, like physiological and psychological. It is a collective responsibility of the society to protect and care to enable them to grow healthy. The focus of health care services, therefore, has now shifted from the care during illness to disease prevention, health promotion and wellness. Worldwide history gives evidences indicating usage of children as a “commodity” for fulfilling the adult’s various purposes, including increasing population and sharing the work. Due to lack of clear understanding regarding childhood illness and management, children who are ill or handicapped were considered burden and not useful to family, and hence were abandoned. It took a long time to change this deeprooted concept and in 19th century, child healthcare gained a much better understanding regarding various child care, illness and wellness.

HISTORICAL PERSPECTIVES ON CHILD CARE PRACTICES Prehistoric Times Fossil studies highlight existence of child care practices in pre historic/stone age period. These included carrying small children at back, feeding and closely observing their growth. The mother had the responsibility to prepare their children to follow their customs and beliefs. The children will be then taught during their late childhood period regarding their customs, beliefs, skills, and history of their tradition (mostly tribal tradition). The children enjoyed a high level of freedom and all were prepared for continuation of their tradition, i.e., hunting, protection from animals and natural hazards.

Ancient Civilization The peculiar feature of ancient civilization is evolution of various trades, like hieroglyphics (Scribe tradition of Egypt), peasants, artisan, king, farmer, etc. and carrying

Unit I  Introduction: Modern Concepts of Child Care

4 the trade from generation to generation. Children during ancient period therefore enjoyed varying degree of status as like king’s children, artisan’s children, farmer’s children, etc. The philosophy of child care aspects was same as to prepare the children to continue their tradition but the traditions were different and so were the child care practices. Families with large members were regarded as sign of prosperity and a result of God’s blessing. Ailments, illness, diseases, handicaps all existed during this time and treatments in practice were mostly herbal in most of the traditions, namely Indians, Chinese, Jews and others. Mosaic Law of Jews is famous for hygienic measures that has been reported as influenced mother and child care. Charity services are another remarkable milestone during ancient times focusing on children who were orphaned (especially of soldiers) and widows in the form of adoption law, financial and medical support. At the same time fathers were given authority to punish, imprisonment, death, or even sale to slavery (Romans).

were invented. The famous book Emilie written by Rousseau, has a section on the rights, hygiene and nutrition of children and infants.

Modern World Knowledge of human body gained a momentum as a result of advancement in scientific approaches in gaining knowledge and philosophy of humanitarianisms. Knowledge of human body then branched into various diseases and treatment modalities. The significant contribution of modern world includes water purification, waste and sewage disposal, pasteurization of milk, immunization program, production of antibiotics. Maternal and Child Health (MCH) Program that include free food and medicines, Child Labour Act, introduction of more hospitals and child care centers.

Changes in Family Type and Culture

Survival of human kind, especially children were affected very badly during this period due to war, epidemic and pandemic conditions. The Black Death of 1347 had taken one-fourth of the entire population. The history indicated that the first asylum to take care of children who were orphaned was founded in Italy in 787 AD. However, due to poor general level of public health and hygiene, the conditions of these asylums were very poor.

Migration and movement of families from one place to other created a break in the extended family system. As all members live together and inter dependant in extended system, the children were more secure. They are taken care of well and grow in their tradition-bound customs and practices. However due to migration owing to many reason but mostly for farming, the extended family system was broken into nuclear family set up. This led the family to pass through large amount of strangeness and mixing of culture, etc. The support that was there with extended family system was then shifted to public health agencies or governmental programs.

Renaissance and Early Modern World (1350–1800 AD)

Evolution of Pediatrics in Medical and Nursing Practice

The Chinese invention of printing and manufacture of paper made a drastic change in the human life world around. Knowledge was enhanced and two books; The Book of Children by Thomas Phaer (England) and Children’s Book by Felix Wűrtz were published in 16th century. Another important person of this era is St. Vincent Paul who is known as patron saint of orphan who struggled to arouse public interest in the care of the children. The early modern world showed emergence of middle class initially and Industrial Revolution in later period as a result of rapid growth in industry from home to large factories with machines. The Industrial Revolution led to accidents, sickness and the death toll raised dangerously owing to various factors. These were colonization, forcing children to work for long hours, low wage, poor sanitation and overcrowding in settlements. Despite the unhealthy situation, certain ray of hopes also occurred during this period. Edward Jenner (England) developed small pox vaccine, William Harvey discovered circulation of blood. Microscope, thermometer and forceps

Hippocrates (460–377 BC) and Celsus (first century AD) have been recorded as pioneers who described about difference in treatment of children. However, the term pediatrics is originated from Greek and the meaning is child cure (“pais”= child). The care taking behavior of their children has been observed as strongly existing in human’s culture since the ancient period. Indian traditional medicine has described about child care. Abraham Jacobi, a US-based Professor in pediatrics is known as Father of Pediatrics (1870). He set up a hospital for children and paved a path for a specialized training in pediatrics. This corresponds that the evolution of the modern system of child health is not very old as compared to other healthcare system. As of now, the healthcare practices of children are not only infant feeding or a few diseases management, but encompass a comprehensive approach from conception to maturity. The Henry Street Settlement House established by Lillian Wald in 1900 at New York city, is regarded as the start of public health nursing oriented toward providing services of home nurse visiting to teach mothers about health care.

Medieval World (450–1350 AD)

5

z Strict

menstrual hygiene going to her parental home for delivery z Celebrations when pregnant lady achieves 32 weeks. z Abstinence during pregnancy. z 10 days of strict isolation of mother and new born from other members (prevention of infection) z Cleanliness and hygiene, warmth, measures of lying in room z Mother

Trend of Preventive and Promotive Child Health Practices Public health science originated from England in 1840 as the public health was affected by industrialization, colonization, lack of facility for safe water and waste disposal. In India, public health measures primarily were disease oriented and started since independence. MCH services have been given importance since 4th Five-year plan, until then it was of population control programs. Under the CSSM program, expansion of MCH services in large scale was done for implementation through Primary Health Centers (PHCs) and Sub-centers. These include the child survival components consisting of new born care, immunization, management of acute diarrhoea and respiratory infections, prevention of hypothermia, infections, promotion of exclusive breast feeding and referral of sick new born. In 1997, the MCH programs then further expanded and integrated along with the Reproductive Child Health (RCH) package of National Family Welfare program. The focus of RCH-I program was prevention and management of unwanted pregnancy, antenatal, delivery and postnatal services, child survival services of newborn and infants, management of reproductive tract infections and STDs. The RCH aimed to utilize integrated delivery of the services with quality, especially in neonatal and perinatal health. Besides above, ICDS program was launched in 1975 with an aim to cover 70% of community development blocks, and 260 urban slum pockets. The beneficiaries included children under six years of age, expectant and lactating mother and adolescent girls.

HEALTH CARE DELIVERY SYSTEM IN INDIA The health system in India is a mix of public and private sector with the non-governmental organizations (NGOs) playing a small yet important role. The public health system in India is primarily under the purview of State Governments, with the Central Government providing broad policy guidelines, technical assistance, and additional resources. The health system in India is well structured (Fig. 1.1). z Sub-center

(SC): It is the most peripheral health service delivery point in the health care infrastructure. Each SC is staffed by a female worker, auxiliary nurse midwife (ANM) and a male worker. SCs cover a population of 3,000–5,000. z Primary Health Center (PHC): The next level, caters to a population of 30,000 and overseeing 6–8 SCs. A PHC is staffed by one or two general physicians, a lady health visitor (LHV) and one or more ANMs. Ministry of Health and Family Welfare (MoHFW) is transforming existing Sub-centers and Primary Health Centers across the country into Ayushman Bharat – Health and Wellness Centers (AB-HWCs). Health and Wellness Centers aim to provide Comprehensive Health Care Services closer to the community and reduce financial hardship. In 2017, the National Health Policy was launched, which endorsed the establishment of Health and Wellness Centers (HWCs). z Community

Health Center (CHC): For every 3–4 PHCs there is a provision for CHCs. About half of CHCs nationwide have been designated as first referral units (FRUs) and are staffed by a pediatrician, obstetrician, anesthetist, several general physicians, nurses and paramedics, and are able to provide emergency obstetric and newborn care. There are 2–4 FRUs in each district, and one or more multi-specialty hospitals at the district headquarters. z District hospitals: These are the final referral centers for the primary and secondary levels of the public health system. z Hospitals, medical colleges and research institutes: These are referral hospitals with specialized facilities.

Figure 1.1: Health care delivery system in India

Chapter 1  Child Care Concepts

The Indian traditional medicine Ayurveda and Siddha were in practice since Vedic times (5000 BC) and both have descriptions about maternal and child care components. Maternal and child care was practiced by women of special group (Dai) and hygiene was given priority during delivery and lactation. The rituals during pregnancy and childhood were true representation of the need of the child during developmental stages. For example, special and rich food with more of sweets, ghee and nuts and less spicy to meet the energy and other nutrients required for growth as well as birth process. Some of the good practices existed among various groups of India are listed here:

Unit I  Introduction: Modern Concepts of Child Care

6 feeding. Breast feeding should be started immediately after birth and to be continued exclusively for six months. Appropriate and adequate complementary feeding must begin thereafter and breast-feeding can continue for up to two years.

NATIONAL POLICIES, LEGISLATION AND AGENCIES RELATED TO CHILD WELFARE National Policies z National

Policy for Children, 1974 states that the State shall provide adequate services toward children, both before and after birth and during the growing stages for their full physical, mental and social development. z National Nutrition Policy, 1993 was adopted by the Government of India under the aegis of the Department of Women and Child Development. It advocated strategy for eradicating malnutrition and achieving optimum nutrition for all. The policy advocates monitoring of nutrition levels across the country and sensitising government on the need for good nutrition. It also includes the Food and Nutrition Board, which develops posters, audio jingles and video spots for disseminating correct facts about breastfeeding and complementary feeding. z National Population Policy (NPP), 2000: It reaffirmed the Government's commitment toward voluntary and informed choice, target-free approach and achievement of replacement level of fertility by addressing the issues of contraception, maternal health and child survival. Some of the goals of NPP were:  Make school education up to age 14 free and compulsory, and reduce drop outs at primary and secondary school levels for both boys and girls.  Reduce IMR to below 30 per 1000 live births and reduce MMR to below 100 per 100,000 live births.  Achieve universal immunization of children against all vaccine preventable diseases.  Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of age.  Achieve 80% institutional deliveries and 100% deliveries by trained persons.  Achieve 100% registration of births, deaths, marriage and pregnancy. z National Charter for Children, 2003: It emphasizes Government’s commitment to children's rights to survival, health and nutrition, standard of living, play and leisure, early childhood care, education, protection of the girl child, empowering adolescents, equality, life and liberty, name and nationality, freedom of expression, freedom of association and peaceful assembly, the right to a family and the right to be protected from economic exploitation and all types of abuse. z National Plan of Action for Children, 2005: It includes strategies for improving the nutritional status of children, reducing IMR, increasing enrolment ratio, reducing drop-out rates, universalization of primary education and increasing coverage for immunization. z National Guidelines on Infants and Young Child Feeding, 2006: These guidelines emphasize the importance of breast

Schemes of Ministry of Women and Child Development Related to Child Welfare The Integrated Child Development Services Scheme (ICDS), 1975 It is one of the most comprehensive schemes on child development in the country run by Ministry of Women and Child Development since 1975 in pursuance of the National Policy for Children. It aims at providing services to pre-school children in an integrated manner to ensure proper growth and development of children in rural, tribal and slum areas. This centrally sponsored scheme also monitors nutrition of children. The beneficiaries under the Scheme are: z Children

z Pregnant

in the age group of 0–6 years women and lactating mothers

Objectives of the Scheme are: z To

improve the nutritional and health status of children in the age-group 0–6 years z To lay the foundation for proper psychological, physical and social development of the child z To reduce the incidence of mortality, morbidity, malnutrition and school dropout z To achieve effective co-ordination of policy and implementation amongst the various departments to promote child development z To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education. Services under ICDS: The ICDS Scheme offers a package of six services, which are as follows: 

z Supplementary

Nutrition non-formal education z Nutrition and health education z Immunization z Health check-up and z Referral services z Pre-school

The various initiatives under ICDS umbrella are:

Anganwadi Services z Scheme

for Adolescent Girls (Kishori Shakti Yojna), 1991: Services for adolescent girls were not covered by any health and social welfare program, whereas girls in this crucial groups need special attention. Under this scheme all adolescent girls in the age group of 11–18 years

7

Anemia Mukt Bharat (Fig. 1.2) initiative of MoHFW, focusses on six target beneficiary groups, through six interventions and six institutional mechanisms (6 × 6 × 6 strategy) to achieve the envisaged target under the POSHAN Abhiyan by 2022.

Integrated Child Protection Scheme (ICPS) It is a centrally sponsored scheme aimed at building a protective environment for children in difficult circumstances, as well as other vulnerable children, through Government-Civil Society Partnership

Balika Samriddhi Yojana (BSY), 1997 The objective of this centrally-sponsored scheme is to provide postdelivery grant of `500/- to the mother of girl child belonging to BPL families and later scholarships to the girl child when she goes to school. The aim is to enhance the status of girl child by helping society to change negative attitude about girl child, and ensure her survival. It ultimately aims at ensuring that girl child is educated and not married before the age of 18 years.

Swadhar Scheme, 2001 It was launched for the benefit of women/girls in difficult circumstances like trafficking and sexual abuse.

Ujjawala Scheme, 2007 It is a comprehensive scheme for prevention of trafficking and rescue, rehabilitation and re-integration of women and child victims of trafficking and commercial sexual exploitation.

National Legislations The existing laws relating to children are as follows: z The

Protection of Children from Sexual Offences (POCSO) Act, 2012: This act defines a child as any person below the age of 18 years and provides protection to all children under the age of 18 years from the offences of sexual assault, sexual harassment and pornography. The Act provides for stringent punishments, which range from simple to rigorous imprisonment of varying periods or fine, as decided by the Court. An offence is treated as “aggravated” when committed by a person in a position of trust or authority of child such as a member of security forces, police officer, public servant, etc. z The National Commission for Protection of Child Rights, 2007: It was set up under the Commission for Protection of Child Rights Act, 2005, an Act of Parliament (December 2005). The Commission’s Mandate is to ensure that all laws, policies, programs, and administrative mechanisms are in consonance with the Child Rights perspective as enshrined in the Constitution of India and also the UN Convention on the Rights of the Child. The Child is defined as a person in the 0 to 18 years age group. z Prohibition of Child Marriage Act, 2006: To ensure that child marriage is eradicated from within the society, the Government of India enacted this Act, replacing the earlier legislation of Child Marriage Restraint Act, 1929. This legislation is armed with enabling provisions to prohibit child marriages, protect and provide relief to victims and enhance punishment for those who abet, promote or solemnize such marriages. z The Juvenile Justice (Care and Protection Act) Amendment Act, 2006: It is an Act to consolidate and amend the law relating to juveniles in conflict with law and children in need of care and protection, by providing for proper care, protection and treatment by catering to their development needs, and by adopting a child-friendly approach in the adjudication and disposition of matters in the best interest of children and for their ultimate rehabilitation. Some of the features of the Juvenile Justice Act are:  It provides a uniform legal framework for juvenile justice in the country to ensure that no child under any circumstances is put in jail.  It envisages specialized approach toward prevention and treatment of juvenile delinquency in keeping with the developmental needs of children.  It establishes norms and standards for administration of juvenile justice in terms of investigation, care, treatment and rehabilitation.

Chapter 1  Child Care Concepts

receive the common services, like watch over menarche, immunization, general health check-ups once in every six-months, training for minor ailments, deworming, prophylactic measures against anemia, goiter, vitamin deficiency, etc., and referral to PHC, district hospital in case of acute need. z Rajiv Gandhi National Crèche Scheme for the Children of Working Mothers, 2006: The creche services for children of working mothers were provided earlier under the Scheme for Crèches for the Children of Working and Ailing Mothers and the National Crèche Fund. The scheme and the corpus have been merged and new scheme, namely, Rajiv Gandhi Crèche Scheme for Children of working Mothers is under implementation since 1st January, 2006 to provide better and improved Crèche/Day Care facilities. z ‘Pradhan Mantri Matru Vandana Yojana’ (PMMVY), 2017: Under PMMVY, a cash incentive of `5000/– is provided directly to the Bank/Post Office Account of Pregnant Women and Lactating Mothers for first living child of the family subject to fulfilling specific conditions relating to Maternal and Child Health. z National Nutrition Mission renamed as Poshan Abhiyaan, 2018: It has been aimed at reducing the level of stunting, under-nutrition, anemia and low birth weight babies. It will create synergy, ensure better monitoring, issue alerts for timely action. Under Poshan Abhiyaan, Intensified National Iron Plus initiative (I-NIPI) and Anemia Mukt Bharat were started.

Unit I  Introduction: Modern Concepts of Child Care

8

Figure 1.2: Anemia Mukt Bharat 



It lays down appropriate linkage and co-ordination between the formal system of juvenile justice and voluntary organizations; and defines the roles and responsibilities of both. The first central legislation on Juvenile Justice was passed in 1986, by the Union Parliament, providing a

uniform law on juvenile justice for the entire country. The JJ Act, 1986 was repealed and the Juvenile Justice (Care and Protection of Children) Act, 2000 was passed taking into consideration all the International Standards prescribed as per the Convention on the Rights of the child. Later on again it was amended in 2006.

9 Preconception and Prenatal Diagnostic Techniques (Pcpndt), (Prohibition of Sex Selection) Act, 1994: PreNatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 (PNDT), was amended in 2003 by the Parliament of India to the Pre-Conception and PreNatal Diagnostic Techniques (Prohibition of Sex Selection) Act (PCPNDT Act) to improve the regulation of the technology used in sex selection. The law provides for the Prohibition of sex selection, before and after conception and regulation of prenatal diagnostic techniques (e.g., amniocentesis and ultrasonography) for detection of genetic abnormalities, by restricting their use to registered institutions. The Act mandates compulsory registration of all diagnostic laboratories, all genetic counselling centers, genetic laboratories, genetic clinics and ultrasound clinics. z Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992: It prohibits the advertisement of infant milk substitutes and feeding bottles to ensure that no impression is given that feeding of these products is equivalent to, or better than, breastfeeding. z Child Labor (Prohibition and Regulation) Act, 1986: It has been enacted to prohibit the engagement of children (who has not completed their 14 years of age) in certain employments and to regulate the hours and conditions of work of children in certain hazardous employments. Child Labor (Prohibition and Regulation) Amendment Bill 2016 was passed by Rajya Sabha on July 20, 2016, as per the Child Labour Act “a child is defined as any person below the age of 14, prohibits employment of a child in any employment including as domestic help.” z Immoral Traffic Prevention Act, 1986: It prescribes stringent action against those inducting children (below 16 years) and minors (16–18 years) in the offence of procuring, inducing or taking a person for the sake of prostitution. z The Children Act, 1960: It’s an Act to provide care, protection, maintenance, welfare, training, education and rehabilitation of neglected or delinquent children and for the trial of delinquent children in the Union territories. z The Child Marriage Restraint Act, 1929: An Act to restrain the solemnization of child marriage. In this Act, “child” means a person who, if a male, has not completed twenty-one years of age, and if a female, has not completed eighteen years of age. It says, whoever, being a male above eighteen years of age and below twenty-one, contracts a child marriage shall be punishable with simple imprisonment which may extend to fifteen days, or with fine which may extend to one thousand rupees, or with both.

Agencies Related to Welfare of Children These are classified as international and national agencies:

International Agencies z World

Health Organization (WHO): WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. z United Nations Children’s Fund (UNICEF): UNICEF has been working in India since 1949. It is the largest UN organization, committed to working with the Government of India to ensure that each child born in this country gets the best start in life, thrives and develops to his or her full potential. UNICEF uses its community-level knowledge to develop innovative interventions to ensure that women and children are able to access basic services such as clean water, health visitors and educational facilities, and that these services are of high quality. At the same time, UNICEF reaches out directly to families to help them to understand what they must do to ensure their children thrive. It recognizes that the health, hygiene, nutrition, education, protection and social development of children are all connected. UNICEF’s work is centered on children from neonatal stages to adolescence. There is also a special focus on social inclusion in all these programs. z Food and Agriculture Organization (FAO) 1945: It helps the people of the world to fight against hunger and malnutrition. z The United Nations Educational, Scientific and Cultural Organization (UNESCO) It helps to develop text books and promotion and teaching of national languages to the children of migrant workers, training of staff for preschool children and assists projects to set up production of children’s books and libraries, especially for destitute children. z USAID-US Agency for International Development z CARE-Cooperative for Assistance and Relief Everywhere

National Agencies z Indian

Red Cross Society, 1920: The Indian Red Cross is a voluntary humanitarian organization having a network of over 1100 branches throughout the country, providing relief in times of disasters/emergencies and promotes health and care of the vulnerable people and communities. z Ford Foundation, 1936: Its aim is to reduce poverty and injustice, strengthen democratic values, promote international cooperation, and advance human achievement. z Kasturba Gandhi Memorial Trust, 1945: It was established as a result of the national endeavor, led by Mahatma Gandhi, to address the issues of women in Rural India. Its activities include Maternity and Child Welfare, home for women destitute, trainings at anganwadi centers, organizing medical camps, etc.

Chapter 1  Child Care Concepts

z The

Unit I  Introduction: Modern Concepts of Child Care

10 z All

India Blind Relief Society, 1946: It functions for the relief of the blind. z Indian Council for Child Welfare (ICCW), 1952: It is a national level voluntary organization which stands for the development of child welfare. The objective is to initiate, undertake or aid directly or through its State/ Union Territory Councils or affiliated bodies, schemes for continuance of child welfare in India. Activities of ICCW include:  Advocating Rights of children  Honoring Children for Bravery, Honoring Child Artists  National Integration Camps/Adventure Camps  Creches for children of working mothers  Training programs for child care workers  Sponsorship for School Education of under-privileged children  Projects for Street and Working children  Scrutiny of Adoption Cases, Rehabilitation of Abandoned Children  Institutional and day care services for differently-abled children z Central Social Welfare Board, 1953: It was established by a Resolution of Govt. of India to carry out welfare activities for promoting voluntarism, providing technical and financial assistance to the voluntary organisations for the general welfare of family, women and children.  z Mobile Crèches, 1969: The founder, Meera Mahadevan, set up the first “mobile creche” in 1969 as a spontaneous response to the neglected children she saw on the site of the Gandhi Centenary Exhibition, in Delhi. From that rudimentary shelter, the journey began toward gaining entry into other construction sites and ensuring basic minimum care for the children of the vast migrant labor force belonging to the poorest strata of society. It provides childcare services to 6000 children in a year, at 21-day care centers at construction sites across Delhi, NOIDA (Uttar Pradesh) and Gurgaon (Haryana), from 9.00 a.m. to 5.00 p.m., six days a week. It works with corporate partners, including construction companies, and advocate for right policies and programs for children with the state/central governments. z Child Rights and You (CRY), 1979: It is an NGO, working towards creating happier and healthier childhood. It works in areas such as education, malnutrition, immunization, protection from trafficking, child marriage and child abuse. z Smile Foundation, 1982: It identifies out-of-school children from remote villages, tribal areas and urban slums, and provides them quality education. In addition to this, it also looks after their health, nutrition, and holistic development through participation in co-curricular activities. z Childline, 1996: It is India’s first 24-hour, free, emergency phone service (1098) for children in need of aid and assistance. It responds to the emergency needs of children and links them to services for their long-term care and

rehabilitation. It is a platform bringing together the Ministry for Women and Child Development, Government of India, Department of Telecommunications, street and community youth, non-profit organizations, academic institutions, the corporate sector and concerned individuals. It works for the protection of the rights of all children in general. But special focus is on all children in need of care and protection, especially the more vulnerable sections, which include street children, child laborers, victims of flesh trade, differently abled children, substance abuse, etc. z SOS Children’s Villages: SOS Children’s Villages take action for children as an independent non-governmental social organization. It works in the spirit of United Nations Convention on the rights of the child and promotes these rights around the world. This organization pioneers a family approach to the long-term care of orphaned and abandoned children. At present there are about 31 children’s villages taking care of around 6000 children in the country. The concept is based on four principles which are as follows: 1. The mother: Each child has a caring parent 2. Brothers and sisters: Family ties grow naturally 3. The house: Each family creates its own home 4. The village: The SOS family is a part of the community

NATIONAL HEALTH PROGRAMS RELATED TO CHILDREN The National Health Policy of 1983 and the National Health Policy of 2002 have served well in guiding the approach for the health sector in the Five-Year Plans. The National Health Policy, 2017 (NHP, 2017) seeks to reach everyone in a comprehensive integrated way to move toward wellness.  It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost. The specific child-related goals are: z Reduce Under Five Mortality to 23 by 2025 and MMR from

current levels to 100 by 2020. infant mortality rate to 28 by 2019. z Reduce neonatal mortality to 16 and still birth rate to “single digit” by 2025. z Reduce

The Ministry of Health, Government of India with help of central health council has taken several initiatives in launching programs aimed at controlling or eradicating diseases which cause considerable morbidity and mortality in India. New programs are being added and existing ones are modified in response to changing epidemiology of disease, host or parasites. The important National Health Programs are listed here:

Maternal and Child Health Program, 1951 The goal of this program was to promotive, preventive and planned health care activities for mothers and children.

11

z Immunization z Oral

rehydration therapy, acute respiratory infections treatment and provision of 6 monthly doses of vitamin A to children z Creation of first referral units (FRUs) for immediate and improved obstetric care of mothers. After the international conference on population and development in 1994, the package of services became FP + CSSM + Prevention of RTI/STD and AIDS, and the program was called the Reproductive and Child Health (RCH) approach to family welfare. It believes in the philosophy that “people have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well-being and couples are able to have sexual relations free of fear of pregnancy and of contracting diseases.” The program also covers the reproductive health needs of adolescents, reproductive rights, women’s empowerment and female literacy.

School Health Program, 1977 The National School Health Program was launched in 1977 as Centrally sponsored scheme.

Objective of the Program z To

prepare younger generation to adopt measures to remain healthy so as to help them to make the best use of educational facilities to utilize in a productive and constructive manner, to enjoy recreation and to develop concern for others. z To help the younger generations to become healthy and useful citizens who will be able to perform their role effectively for the welfare of themselves, their families, the community at large and the country as a whole. z Promotion of positive health of School Children. z Prevention of disease. z Early diagnosis, treatment, follow up and referral. z Awakening of health consciousness. z Provision of healthful environment.

Strategies z To conduct as many health check-up as possible among the

School Children by increasing the number of school visit in every district. z To train more medical officers and school teachers at every district on school health Program particularly on personal hygiene, household and school environment sanitation, detection of more children with health problems and give treatment and follow up.

Diarrheal Disease Control Program, 1978 The main objective of the program was to prevent death due to dehydration caused by diarrheal diseases among children under 5 years of age due to dehydration. Health education aimed at rapid recognition and appropriate management of diarrhoea has been a major component of the CSSM. Under the RCH program, ORS is supplied in the kits to all subcenters in the country every year.

Immunization Program, 1978 1978: Immunization Program in India was introduced in 1978 as Expanded Program of Immunization (EPI) by the Ministry of Health and Family Welfare. 1985: EPI was modified as Universal Immunization Program (UIP). The objectives of the program were as follows: z Rapidly

increasing immunization coverage the quality of services z Establishing a reliable cold chain system to the health facility level z Introducing a district wise system for monitoring of performance z Achieving self-sufficiency in vaccine production z Improving

The infants are immunized against six vaccine preventable diseases, i.e., tuberculosis, diphtheria, pertussis, poliomyelitis, measles and tetanus. 2014: To accelerate the coverage of immunization, Mission Indradhanush was envisaged and implemented since 2015 to rapidly increase the full immunization coverage to 90%. The Mission Indradhanush, depicting seven colors of the rainbow, targets to immunize all children against seven vaccine preventable diseases, namely Diphtheria, Pertussis, Tetanus, Childhood Tuberculosis, Polio, Hepatitis B and Measles. 2017: Intensified Mission Indradhanush was launched.

Acute Respiratory Infection Control Program (ARI), 1990 The ARI Control Program was started in India in 1990. It sought to introduce scientific protocols for case management of pneumonia with co-trimoxazole. Initially 14 pilot districts were selected and later on new districts were included. A review of the health facility done in 1992 revealed that

Chapter 1  Child Care Concepts

The program started in 1951 with family planning services, and was called the Family Planning Program; it continued under this name until about 1977. Family planning methods were propagated among public. In 1971, Medical Termination of Pregnancy (MTP) was liberalized as a health measure to save women from unhealthy abortions resulting in morbidity and mortality. After 1977, Maternal and Child Health (MCH) services became an important component of the program’s services and the program was renamed as the Family Welfare Program. In the late eighties, the scope of MCH services expanded in the form of CSSM including activities like:

Unit I  Introduction: Modern Concepts of Child Care

12 although 87% of personnel were trained and the drug supply was regular, there were problems in correct case classification and treatment. Since 1992, the program was implemented as part of CSSM and later with RCH. Cotrimoxazole tablets are supplied as part of drug kit for use by different category of workers for managing cases of Pneumonia. Under RCH-II, activities are proposed to be implemented in an integrated way with other child health interventions.





Child Survival & Safe Motherhood Program (CSSM): (1992–1996) It is aimed at addressing the major causes of maternal and childhood mortality.

Components of CSSM Program z Advise

on breastfeeding: Exclusive breastfeeding in the first 6 months of life to be propagated as an ideal method of feeding. z Care of newborn infant: The main aim of child survival program is to reduce infant mortality. Since neonatal deaths constitute almost half of infant mortality, it is necessary to pay attention to such measures which reduce mortality like safe delivery services, exclusive breastfeeding and quick referral of sick neonates. z Resuscitation: If the infant fails to cry immediately after birth, the initial steps of resuscitation must be started. z Low birth weight infants: The TBA and other workers must be familiarized with the features of illnesses in LBW babies and the baby referred to a PHC. z Pregnant women:  Essential care for all: It includes registration by 12–16 weeks, antenatal check-up at least three times, immunize with TT, give Iron and Folic acid 1 OD × 100 days, treat those with clinical anemia: 2 OD × 100 days, deworm with mebendazole during 2nd/3rd trimester, (where prevalence rates of hookworm infestation are high), safe and clean delivery services, prepare the woman for exclusive breastfeeding and timely weaning,



postnatal care, including services for limiting and spacing births. Early detection of complications: Like anemia, bleeding, weight gain of more than 3 kg in a month, and systolic BP of 140 mm Hg or more or diastolic BP of 90 mm Hg or more, fever 39°C and above after delivery or after abortion and prolonged or obstructed labor. Emergency care for those who need it: It includes early identification of obstetric emergencies, provide initial management and refer to referral units using fastest available mode of transport. Women in the reproductive age group: It involves counseling on small family norms, spacing of birth, information on MTP, IUD and family planning services.

Reproductive and Child Health Program (1997, 2005) The program was launched on 15th October 1997, based on International Conference on Population and Development held at Cairo in 1994. The program aims to universalize the immunization, ante-natal care, skilled attendance during delivery as well as for common childhood ailments, improving neonatal care in at all levels, hospital, homes and community to substantially reduce the infant mortality. This program aimed at eradication of polio virus while selectively introducing Hepatitis B. The scheme is partly funded by the World Bank and European Commission and run by Department of Health and Family Welfare. The second phase of Reproductive and Child Health (RCH) program, i.e., RCH–II commenced from 1st April, 2005. The main objective of the program is to bring about a change in mainly three critical health indicators, i.e., reducing total fertility rate, IMR and MMR with a view to realizing the outcomes envisioned in the MDGs, the National Population Policy 2000, and the Tenth Plan Document, the National Health Policy 2002 and Vision 2020 India. Major Elements of RCH Program are listed in Table 1.1.

Table 1.1: Major elements of RCH program Reproductive health elements

Child survival elements

• Responsible and healthy sexual behavior • Interventions to promote safe motherhood • Essential obstetric care for all prevention of unwanted pregnancies • Increase access to contraceptives, emergency contraceptives • Safe abortion pregnancy and delivery services • First Referral Units (FRUs) for emergency obstetric care • Management of RTIs/STDs • Infertility & gynecological disorders • Referral facilities by government/private sector for pregnant woman at risk • Reproductive health services for adolescent health

• Essential newborn care • Prevention and management of vaccine preventable disease • Urban measles campaign • Elimination of neonatal tetanus • Cold chain system, polio Eradication: Pulse Polio Programs • Hepatitis B Vaccine, MMR Vaccine • Global alliance for vaccine and immunization • Diarrheal control program and ORS program • Prevention and control of vitamin A deficiency among children

13

Essential obstetrical care

Emergency obstetrical care

Strengthening referral system

• Institutional delivery • Skilled attendant at delivery • Policy decision

• Operationalizing first referral units • Operationalizing PHCs and CHCs for round the clock delivery services

• Training of doctors and nurses in life saving anesthetic skills for emergency obstetric and neonatal care • Setting up of blood storage centers at FRUs according to GoI guidelines.

Essential Components of RCH Program

National Health Mission, 2013

z Prevention

National Rural Health Mission (NRHM) was launched in April 2005 and it morphed into National Health Mission (NHM) with launch of National Urban Health Mission (NUHM) during 2013. Thereafter, NRHM and NUHM became two sub-missions under the overarching NHM. The main programmatic components include Health system strengthening in rural and urban areas, Reproductive MaternalNeonatal-Child and Adolescent Health (RMNCH+A) and Communicable and Non-Communicable Diseases. The NHM envisages achievement of universal access to equitable, affordable and quality healthcare services that are accountable and responsive to people’s needs.

and management of unwanted pregnancy. care that includes antenatal, delivery and postpartum services. z Child survival services for newborn and infants. z Management of Reproductive Tract Infection (RTIs) and Sexually Transmitted Infections (STIs). z Maternal

The major strategies under RCH II are shown in Table 1.2.

Integrated Management of Neonatal and Childhood Illness (IMNCI), 1996 Integrated Management of Neonatal and Childhood Illness  (IMNCI) was launched in 1996 by WHO and UNICEF. It is an integrated strategy for delivering a package of child health services, which takes into account many factors that must be addressed to ensure the well-being of the whole child. It is based on the rationale that decline in child mortality rates is not necessarily dependent on the use of sophisticated and expensive technologies but rather on a holistic approach that combines the use of strategies that are cheap and can be made universally available and accessible to all. The strategy also includes early identification of serious condition and urgent referrals to the nearest health facilities. In India, neonatal deaths account for almost 50% all under 5 child deaths, therefore GoI extended IMCI to include neonatal health also calling it as IMNCI (Integrated management of neonatal and childhood illness). IMNCI is a component of the World Bank supported RCH II program. It is being implemented through a joint effort of UNICEF, National Rural Health Mission (NRHM), Government and other child survival partners. These guidelines recommend standardized case management procedures based on two age categories: z Up

to 2 months and z 2 months to 5 years. The strategy includes three main components: 1. Improvements in the case-management skills of health staff through the provision of locally-adapted guidelines on Integrated Management of Neonatal and Childhood Illness and activities to promote their use. 2. Improvements in the overall health system required for effective management of neonatal and childhood illness. 3.  Improvements in family and community health care practices.

Initiatives under NHM z Janani

Suraksha Yojana (JSY) 2005, aims to reduce maternal mortality among pregnant women by encouraging them to deliver in government health facilities. Under the scheme, cash assistance is provided to eligible pregnant women for giving birth in a government health facility. z Janani Shishu Suraksha Karyakram (JSSK) 2011: This scheme entitles all pregnant women delivering in public health institutions to free and no expense delivery, including caesarean section. The free entitlements include free drugs, diagnostics, diet, blood, free transport and exemption from all kinds of user charges. Similar entitlements are available for all sick infants (up to 1 year of age) accessing public health institutions. z Facility based newborn care: A continuum of newborn care has been established with the launch of home based and facility based newborn care components. It ensures that every newborn receives essential care right from the time of birth and first 48 hours at the health facility and then at home during the first 42 days of life. Newborn Care Corners (NBCCs) are established at delivery points to provide essential newborn care at birth, while Special Newborn Care Units (SNCUs) at District Hospital/Medical College and Newborn Stabilization Units (NBSUs) at FRUs provide care for sick newborns. z F-IMNCI: It is the integration of the facility based care package with the IMNCI package, to empower the health personnel with the skills to manage newborn and childhood illness at the community level as well as at the facility. Facility-based IMNCI focuses on providing appropriate skills for inpatient management of major causes of Neonatal

Chapter 1  Child Care Concepts

Table 1.2: Strategies under RCH II

Unit I  Introduction: Modern Concepts of Child Care

14 and Childhood mortality such as asphyxia, sepsis, low birth weight and pneumonia, diarrhoea, malaria, meningitis, severe malnutrition in children. This training is being imparted to Medical officers, Staff nurses and ANMs at CHC/FRUs and 24 × 7 PHCs where deliveries are taking place. The training is for 11 days. z Navjat Shishu Suraksha Karyakram (NSSK), 2012: It aims to train health personnel in basic newborn care and resuscitation, has been launched to address care at birth issues i.e., Prevention of Hypothermia, Prevention of Infection, Early initiation of Breastfeeding and Basic Newborn Resuscitation. Newborn care and resuscitation is an important starting-point for any neonatal program and is required to ensure the best possible start in life. The objective of this new initiative is to have a trained health personal in Basic newborn care and resuscitation at every delivery point. The training is for 2 days and is expected to reduce neonatal mortality significantly in the country.

Rashtriya Bal Swasthya Karyakram (RBSK), 2013 Rashtriya Bal Swasthya Karyakram (RBSK) is an important initiative aiming at early identification and early intervention for children from birth to 18 years to cover 4 ‘D’s viz. Defects at birth, Deficiencies, Diseases, Development delays including Disability (Fig. 1.3). The services aim to cover children of 0-6 years of age in rural areas and urban slums in addition to children enrolled in classes 1st to 12th in Government and Government aided Schools. It is expected that these services will reach to about 27 crores children in a phased manner.

Reproductive, Maternal, Newborn, Child and Adolescent Health, 2013 RMNCH+A launched in 2013 looks to address the major causes of mortality among women and children as well as

the delays in accessing and utilizing health care and services. The RMNCH+A strategic approach has been developed to provide an understanding of ‘continuum of care’ to ensure equal focus on various life stages. Priority interventions for each thematic area have been included in this to ensure that the linkages between them are contextualized to the same and consecutive life stage. It also introduces new initiatives like the use of Score Card to track the performance, National Iron + Initiative to address the issue of anemia across all age groups and the Comprehensive Screening and Early interventions for defects at birth, diseases and deficiencies among children and adolescents. The RMNCH+A appropriately directs the States to focus their efforts on the most vulnerable population and disadvantaged groups in the country. It also emphasizes the need to reinforce efforts in those poor performing districts that have already been identified as the high focus districts.

Objectives The 12th Five-Year Plan (2012–17) defined the national health outcomes and the three goals that are relevant to RMNCH+A strategic approach as follows: z Reduction

of Infant Mortality Rate (IMR) to 25 per 1,000 live births by 2017 z Reduction in Maternal Mortality Ratio (MMR) to 100 per 100,000 live births by 2017 z Reduction in Total Fertility Rate (TFR) to 2.1 by 2017 In 2014 the Planning commission was abolished and in 2015 the NITI Aayog, (National Institution for Transforming India) was established with the aim to achieve SDG. NITI Aayog is undertaking the extensive exercise of measuring India and its States’ progress toward the SDGs for 2030, culminating in the development of the first SDG India Index.

Rashtriya Kishor Swasthya Karyakram (RKSK), 2014 The MoHFW launched a health program for adolescents, in the age group of 10–19 years, which targets their nutrition, reproductive health and substance abuse, among other issues. The key principle of this program is adolescent participation and leadership, equity and inclusion, gender equity and strategic partnerships with other sectors and stakeholders. The program envisions enabling all adolescents in India to realize their full potential by making informed and responsible decisions related to their health and well-being and by accessing the services and support they need to do so.

Objectives z Improve

Figure 1.3: 4Ds of Rashtriya Bal Swasthya Karyakram

nutrition, reduce the prevalence of malnutrition and iron deficiency anemia among adolescent girls and boys through weekly iron and Folic Acid Supplementation (WIFS) z Improve sexual and reproductive health (through menstrual hygiene scheme), reduce teenage pregnancies. z Enhance mental health z Prevent injuries and violence

15 substance misuse z Address NCDs. Promote behavior change in adolescents to prevent NCDs such as hypertension, stroke, cardiovascular diseases and diabetes WIFS: The Ministry of Health and Family Welfare has launched the Weekly Iron and Folic Acid Supplementation (WIFS) Program to meet the challenge of high prevalence and incidence of anemia amongst adolescent girls and boys through supervised weekly ingestion of IFA supplementation and biannual helminthic control.

India Newborn Action Plan (INAP), 2014 It was launched in September 2014, for accelerating the reduction of preventable newborn deaths and stillbirths in the country with the goal of attaining ‘Single Digit Neonatal Mortality Rate (NMR) by 2030’ and ‘Single Digit Still Birth Rate by 2030’.

Ayushman Bharat Yojna (National Health Protection Scheme), 2017 Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to “leave no one behind.” Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related components, which are: z Health and Wellness Centers (HWCs): These are envisaged

to deliver an expanded range of services to address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community. z Pradhan Mantri Jan Arogya Yojana (PM-JAY): It is the largest health assurance scheme in the world which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families.

Surakshit Matritva Aashwasan (SUMAN) 2019 The aim is to assure, dignified and respectful delivery of quality healthcare services at no cost and zero tolerance for denial of services to any woman and newborn visiting a public health facility in order to end all preventable maternal and newborn deaths and morbidities and provide a positive birthing experience. National programs related to control of nutritional deficiencies and disorders include: z Midday

Meal Program, 1961: also known as School Lunch Program, started earlier by MHRD, now Ministry of Education.

O  bjective: Is to attract more children for admission to schools and retain them so that literacy improvement of children could be brought about. Midday Meal improves three areas:  School attendance  Reduced dropouts  A beneficial impact on children’s nutrition Principles to be followed while formulating mid-day meals for school children:  Meal should be supplement and not a substitute to the home diet.  Meal should supply at least 1/3rd of the total energy requirement and half of the protein need.  Cost of the meal should be reasonably low.  Easy to cook, devoid of complicated cooking processes.  Use locally available food to reduce the cost of the meal.  Menu should be frequently changed to avoid monotony. Midday Meal Scheme (1995): Also known as National Program of Nutritional Support to Primary Education. It is a centrally sponsored program launched on 15th August 1995 and revised in 2004. Objectives: 1. Universalization of primary education by increasing enrolment, retention and attendance. 2. Impacting on nutrition of students in primary classes. Facilities are:  Free supply of food grain from nearest Food Corporation of India godown at the rate of 100gm/student/day.  Subsidy for transport of food grain.  Each meal provides minimum 300 calories and 8–12 g of protein. z Vitamin a Prophylaxis Program, 1970: Vitamin A prophylaxis program aims at providing vitamin A – 2 lakh IU (110 mg retinol palmitate) to all preschool children, every 6 months. A vitamin A supplementation program has been in operation in India since 1970. It is a part of National Program for Control of Blindness. It utilizes technology developed by National Institute of Nutrition, Hyderabad. It has helped to decrease the preventable blindness in the community. z National Nutrition Anaemia Prophylaxis Program, 1970: The program was launched in 1970 to prevent nutritional anemia in mothers and children. Under this program, the expected and nursing mothers as well as acceptors of family planning are given one tablet of iron and folic acid containing 60 mg elementary iron which was raised to 100 mg elementary iron, however folic acid content remained same (0.5 mg of folic acid) and children in the age group of 1–5 years are given one tablet of iron containing 20 mg elementary iron (60 mg of ferrous sulphate and 0.1 mg of folic acid) daily for a period of 100 days. This program is being taken up by MCH, Division of MOHFW. Now it is a part of RCH program. z Special Nutrition Program, 1970: Launched in 1970, it aims to provide supplementary feeding of about

Chapter 1  Child Care Concepts

z Prevent

Unit I  Introduction: Modern Concepts of Child Care

16 300 calories and 10 g of protein to pre-school children and about 500 calories and 25 g of protein to expectant and nursing mothers for six days a week. This program was operated under Minimum Needs Program. The program was taken up in rural areas inhibited predominantly by lower socioeconomic groups in tribal and urban slums. z Balwadi Nutrition Program, 1970: Fund for the supplementary feeding of Balwadi Nutrition program is given by the Central Government which was launched in 1970-1971 through voluntary organizations. It provides 300 calories and 10 g of protein per child (3–5 years) per day for 270 days a year. z Applied Nutrition Program, 1973: The Applied Nutrition Program (ANP) was introduced as a Pilot Scheme in Orissa in 1963 which later on extended to Tamil Nadu and Uttar Pradesh with the objectives of:  Promoting production of protective food such as vegetables and fruits  Ensure their consumption by pregnant and nursing mothers and children During 1973, it was extended to all the state of the country. The nutritional education was the main focus and efforts were directed to teach rural communities through demonstration how to produce food for their consumption through their own efforts. The beneficiaries are children between 2 and 6 years and pregnant and lactating mothers. Nutrition worth of 25 paise per child per day and 50 paise per woman per day are provided for 52 days in a year. No definite nutrient content has been specified. The idea is to provide better seeds and encourage kitchen gardens, poultry farming, beehive keeping, etc., but this program did not produce any impact.

INTERNATIONALLY ACCEPTED RIGHTS OF THE CHILD The United Nations Convention on the Rights of the Child is a human rights treaty which sets out the civil, political, economic, social, health and cultural rights of children. Nations that approve this convention are bound to it by an  international law. Compliance is monitored by the UN Committee. India is a party to the UN declaration on the Rights of the Child, (1959) thus it adopted a National Policy on Children in 1974. The policy reiterated the constitutional provisions for adequate services to children, both before and after birth and through the period of growth to ensure their full physical, mental and social development. Declaration of the rights of the child, adopted by UN General Assembly Resolution 1386 (XIV) of 10 December 1959 states that: z The

child shall enjoy all the rights set forth in this Declaration. Every child, without any exception whatsoever, shall be entitled to these rights, without distinction or discrimination on account of race, color, sex, language,

religion, political or other opinion, national or social origin, property, birth or other status, whether of himself or of his family. z The child shall enjoy special protection, and shall be given opportunities and facilities, by law and by other means, to enable him to develop physically, mentally, morally, spiritually and socially in a healthy and normal manner and in conditions of freedom and dignity. z The child shall be entitled from his birth to a name and a nationality. z The child shall enjoy the benefits of social security. He shall be entitled to grow and develop in health; to this end, special care and protection shall be provided both to him and to his mother, including adequate pre-natal and post-natal care. The child shall have the right to adequate nutrition, housing, recreation and medical services. z The child who is physically, mentally or socially handicapped shall be given the special treatment, education and care required by his particular condition. z The child, for the full and harmonious development of his personality, needs love and understanding. He shall, wherever possible, grow up in the care and under the responsibility of his parents, and in any case, in an atmosphere of affection and of moral and material security; a child of tender years shall not, except in exceptional circumstances, be separated from his mother. Society and the public authorities shall have the duty to extend particular care to children without a family and to those without adequate means of support. z The child is entitled to receive education, which shall be free and compulsory, at least in the elementary stages. He shall be given an education which will promote his general culture and enable him, on a basis of equal opportunity, to develop his abilities, his individual judgement, and his sense of moral and social responsibility, and to become a useful member of society. z The child shall in all circumstances be among the first to receive protection and relief. z The child shall be protected against all forms of neglect, cruelty and exploitation. He shall not be the subject of traffic, in any form. The child shall not be admitted to employment before an appropriate minimum age of 18 years. z The child shall be protected from practices which may foster racial, religious and any other form of discrimination. He shall be brought up in a spirit of understanding, tolerance, friendship among peoples, peace and universal brotherhood. The constitution of India guarantees all children certain rights, which have been specially included for them. These include: z Right

to free and compulsory elementary education for all children in the 6–14 years age group (Article 21A). z Right to be protected from any hazardous employment till the age of 14 years (Article 24).

17 to be protected from being abused and forced by economic necessity to enter occupations unsuited to their age or strength (Article 39(e)). z Right to equal opportunities and facilities to develop in a healthy manner and in conditions of freedom and dignity and guaranteed protection of childhood and youth against exploitation and against moral and material abandonment (Article 39 (f)). Besides these, they also have rights as equal citizens of India, just as any other adult male or female: z Right

to equality (Article 14). against discrimination (Article 15). z Right to personal liberty and due process of law (Article 21). z Right to being protected from being trafficked and forced into bonded labor (Article 23). z Right of weaker sections of the people to be protected from social injustice and all forms of exploitation (Article 46). z Right

CHANGING TRENDS IN CHILD HEALTH The following are the changing trends in pediatric nursing: z Atraumatic

care: It is the provision of therapeutic care in such a way as to minimize the physical and emotional distress to children and families. The goal of atraumatic care is to “first do no harm”, and two principles that lead to achieving this goal are: (a) prevent or minimize bodily injury and pain and (b) promote a sense of control. z Primary nursing: It is a method of nursing practice which emphasizes continuity of care by having one nurse care for a small group of inpatients within a nursing unit of a hospital. The “primary nurse” is responsible for coordinating all aspects of care for the same group of patients throughout their stay in a given area. z Kangaroo mother care: It is a universally available and biologically sound method of care for all newborns, but in particular for premature babies, with three components: 1. Skin-to-skin Contact, 2 Exclusive breastfeeding and 3. Support to the mother infant dyad. Kangaroo care offers the most benefits for preterm and low birth weight infants, who experience more normalized temperature, heart rate, and respiratory rate, increased weight gain, fewer nosocomial infections and reduced incidence of respiratory tract disease. z Nursing process approach: The nursing process is goaloriented method of caring that provides a framework to nursing care. It involves five major steps (ADPIE):



A - Assess (what data is collected?) D - Diagnose (what is the problem?) P - Plan (how to manage the problem) I - Implement (putting plan into action) E - Evaluate (did the plan work?) z Family-centered care: It is based on the understanding that the family is the child’s primary source of strength and support. Family-centered care improves patient and family outcomes, increases patient and family satisfaction, builds on child and family strengths, increases professional satisfaction, decreases health care costs, and leads to more effective use of health care resources. z Evidence-based practice: It is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. This can help in improving patient safety, reducing health care costs and delivering best quality care. The practice of evidence-based nursing involves: 1. formulation of an answerable question; 2. systematic searching for the research evidence that could be used to answer the question; 3. Critical appraisal of the found literature; 4. Applying evidence in practice. z Child-oriented environment: It refers to organizing the hospital stay in such a way that child feels comfortable and secure. The wards and ICUs must have colorful pictures. A playroom must be available where they can play with toys or learn drawing. The surroundings must be safe, the drugs must be kept in closed, locked cabinet and non-skid surfaces. z Cost containment: It refers to providing high quality care with minimum resources which are available. z High-tech high-touch approach: It means balancing between high-tech skills and high touch skills of life. Human element of high touch allows an emotional attachment to take place. Child needs to be touched, cuddled and hugged.

Summary The concept of child care has progressed immensely from mother centric care to family centered care and promotion of vaccinations. There have been many recent changes in health care delivery systems including health and wellness centers; the laws, health programs, policies and schemes specific related to children. Focus on preventive aspects and evidence-based care is emphasized.

Assess Yourself 1. List the internationally accepted rights of child. 2. Discuss the changing trends in child health nursing. 3. Explain the latest initiatives of government to achieve goals related to child health.

4. Write full forms of: • JSY, JSSY, NSSK, F-IMNCI, UNICEF, CRY, ASHA, ICDS, SNCU, FRU • RKSK, CSSM, RMNCH A, RBSK, POCSO

Chapter 1  Child Care Concepts

z Right

Chapter

2

Preventive Pediatrics Chapter Outline  Introduction

 Child Morbidity and Mortality

 Vaccines

 Accidents in Young Children

 Immunization  Under Five-Clinics/Well Baby Clinics

 Infant Morbidity and Mortality

INTRODUCTION

Types of Immunity

Preventive pediatrics is defined as the prevention of diseases and the promotion of physical, mental, and social well-being for children to reach optimal growth and development. It includes exclusive breastfeeding, timely immunization, understanding the causes of infant mortality and morbidity and taking steps to prevent them.

Innate Immunity or Nonspecific Immunity

IMMUNIZATION Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Vaccines stimulate the body’s own immune system to protect the person against subsequent infection or disease. Immunity is a biological term that refers to a state of having sufficient biological defenses to avoid infection, disease, or another unwanted biological invasion. There are two components of immune system, namely, specific and non-specific. The non-specific components will act as a barrier or as eliminator destroying wide range of pathogens irrespective of their antigenic specificity, whereas, the specific components of the immune system will adapt themselves to generate pathogen-specific immunity whenever a new disease is encountered by our immune system.

It is the natural resistance with which a person is born. It provides resistance through several physical, chemical, and cellular approaches. Microbes enter into the skin through the epithelial layers and physical barriers that line our skin and mucous membranes. Subsequent general defenses include secreted chemical signals (cytokines), antimicrobial substances, fever, and phagocytes activity associated with the inflammatory response. The phagocytes express cell surface receptors that can bind and respond to common molecular patterns expressed on the surface of invading microbes. Through these approaches, innate immunity can prevent the colonization, entry, and spread of microbes.

Acquired/Adaptive Immunity Depending on how the immunity was introduced, acquired/ adaptive immunity is sub-divided into two major types: naturally acquired and artificially acquired. Naturally acquired immunity occurs naturally (unintentionally) through the contact with a disease-causing agent, whereas artificially acquired immunity develops when the disease causing agent is deliberately introduced inside the body from outside such as by vaccination. Naturally and artificially

Chapter 2  Preventive Pediatrics

pter

19

2 Figure 2.1: Types of immunity

acquired immunity can be further subdivided into active and passive immunity (Fig. 2.1).

Active Immunity Active immunity results when exposure to a disease organism triggers the immune system to produce antibodies to that disease. Exposure to the disease organism can occur through infection with the actual disease (resulting in natural immunity), or introduction of a killed or weakened form of the disease organism through vaccination (vaccine-induced immunity). Either way, if an immune person comes in contact with that disease in the future, their immune system will recognize it and immediately produce the antibodies needed to fight it. Active immunity is long-lasting, and sometimes life-long.

Passive Immunity Passive immunity is provided when a person is given antibodies to a disease rather than producing them through his or her own immune system. A newborn baby acquires passive immunity from its mother through the placenta. A person can also get passive immunity through antibody-containing blood products such as immune globulin, which may be given when immediate protection from a specific disease is needed. This is the major advantage to passive immunity; protection is immediate, whereas active immunity takes time (usually several weeks) to develop. However, passive immunity lasts only for a few weeks or months. Only active immunity is long-lasting. Immunization is one of the most well-known and effective methods of preventing childhood diseases. With the implementation of Universal Immunization Program (UIP), significant achievements have been made in preventing and controlling the Vaccine Preventable Diseases (VPDs).

Immunization has to be sustained as a high priority to further reduce the incidence of all VPDs, control measles, eliminate tetanus and eradicate poliomyelitis. India has one of the largest Universal Immunization Programs (UIP) in the world in terms of quantities of vaccines used, number of beneficiaries (27 million infants and 30.2 million pregnant women) covered, geographical spread (29 States and 7 Union Territories) and manpower involved. The national immunization schedule is summarized in Table 2.1.

VACCINES Vaccines are produced from the same microorganisms or toxins that cause disease, but in either case are modified so as to be harmless to humans. Three main substances are used for the production of vaccines: 1. LIVE microorganisms, e.g., weakened measles and polio viruses or tuberculosis bacteria. 2. KILLED microorganisms, e.g., pertussis microorganisms used in DPT production. 3. TOXOIDS, e.g., inactivated toxins such as tetanus toxoid and diphtheria toxoid. In addition, some vaccines are produced using genetic engineering technologies, i.e.,, recombinant DNA hepatitis B vaccine.

Cold Chain The cold chain system is a means for storing and transporting vaccines in a potent state from the manufacturer to the person being immunized. This is a very important component of an immunization program, since all vaccines lose potency over time, especially if exposed to heat, and in addition, some also lose their potency when frozen. It is pointless to immunize

Unit I  Introduction: Modern Concepts of Child Care

20 Table 2.1: National immunization schedule Vaccine

When to give

Dose

Route

Site

TT-1

Early in pregnancy

0.5 mL

IM

Upper arm

TT-2

4 weeks after TT1

0.5 mL

IM

Upper arm

TT-Booster

If received 2 TT doses in pregnancy within the last 3 years

0.5 mL

IM

Upper arm

For pregnant women*

For Infants BCG

At birth or as early as possible till one 0.1 mL (0.05 mL until year of age 1 month of age)

ID

Left upper arm

Hepatitis B—Birth dose

At birth or as early as possible within 24 hours

0.5 mL

IM

Anterolateral side of mid-thigh

OPV-0

At birth or as early as possible within the first 15 days

2 drops

Oral

Oral

OPV-1, 2, 3

At 6, 10, 14 weeks (can be given till 1 year of age)

2 drops

Oral

Oral

Pentavalent 1, 2, 3 (contains DPT, Hep B and Hib)

At 6, 10, 14 weeks (can be given till 1 year of age)

0.5 mL

IM

Anterolateral side of mid-thigh

Rotavirus

At 6, 10, 14 weeks (can be given till 1 year of age)

5 drops

Oral

Oral

IPV

Two fractional doses at 6 and 14 weeks of age

0.1 mL

I/D

Right upper arm

Measles/MR 1st dose 9 completed months–12 months (can 0.5 mL

S/C

Right upper arm

Japanese encephalitis 9 completed months–12 months (JE)-1

0.5 mL

S/C

Left upper arm

Vitamin A (1st dose)

9 completed months–12 months with measles

1 mL (1 Lakh IU)

Oral

Oral

DPT Booster-1

16–24 months

0.5 mL

IM

Anterolateral side of mid-thigh

Measles/ MR 2nd Dose

16–24 months

0.5 mL

S/C

Right upper arm

OPV Booster

16–24 months

2 drops

Oral

Oral

JE 2

16–24 months

0.5 mL

S/C

Left upper arm

Vitamin A (2nd to 9th 16–24 months. Then everyone dose every 6 months up to 5 years of age Dose)

2 mL (2 lakh IU)

Oral

Oral

DPT Booster-2

5–6 years

0.5 mL

IM

Upper arm

TT

10 and 16 years

0.5 mL

IM

Upper arm

be given till 5 years of age)

For Children

*Give TT to a woman in labor if she has not previously received TT

with impotent vaccine. Once vaccine potency is lost, it cannot be regained. The damaged vaccines must be destroyed, leading to inadequate vaccine stocks and wastage of expensive vaccines. For a summary of vaccine sensitivities, see Table 2.2. The cold chain system comprises three major elements: 1. Personnel, who use and maintain the equipment and provide the health service;

2. Equipment for safe storage and transportation of vaccines; the essential cold chain equipment needed to transport and store vaccines within a consistent safe temperature range include:  A refrigerator for storing vaccines  A digital, electronic or mercury/maximum thermo­ meter and chart for recording daily temperature reading

21

Vaccine

Exposure to heat/light

Exposure to cold

Temperature at PHC

Heat and light sensitive vaccines BCG

Relatively heat stable, but sensitive to light

Not damaged by freezing

+2°–8°C

OPV

Sensitive to heat

Not damaged by freezing

+2°–8°C

Measles

Sensitive to heat and light

Not damaged by freezing

+2°–8°C

DPT

Relatively heat stable

Freezes at –3°C (Should not be frozen) +2°–8°C

Hepatitis B

Relatively heat stable

Freezes at –0.5°C (Should not be frozen)

DT

Relatively heat stable

Freezes at –3°C (Should not be frozen) +2°–8°C

TT

Relatively heat stable

Freezes at –3°C (Should not be frozen) +2°–8°C

Freeze sensitive vaccines +2°–8°C

At the PHC level, all vaccines are kept in the ILR for a period of one month at temperature of +2°–8°C Thermo-sensitivity of vaccines Vaccines sensitive to heat • BCG (after reconstitution)      Most • OPV • Measles • DPT • BCG (before reconstitution) • DT, TT, Hep. B, JE          Least

Vaccines sensitive to freezing • Hep-B         Most • DPT • DT • TT            Least

Cold boxes for transporting and storing vaccines Ice packs to keep vaccines cool  Material to separate ice packs from the vaccines when using cold boxes (i.e., shredded paper, cardboard, bubble wrap or Styrofoam). 3. Procedures to manage the program and control distribution and use of the vaccines.  

UNDER FIVE-CLINICS/WELL BABY CLINICS The fact that 50% of the deaths in India occur among the under-five points to the need of special attention toward this age group. The concept of under-five clinics is rather a new one in India although well baby clinics have been successfully running for the number of years purely focused on preventive pediatrics. An under-five clinic combines the concept of prevention, treatment, health supervision, nutritional surveillance, and education into a system of comprehensive system of health care within the resources available in the country, making use of non-professional auxiliaries, thus making the service not only more economical but also available to a larger proportion of children in the community.

Aims and Objectives The aims and objectives of the under-five clinics are as follows:

Figure 2.2: Symbol of under-five clinic

Care in Illness The apex of the symbol (Fig. 2.2) represents “care and treatment of sick children”. This is a mother’s “felt need”. Studies have shown that 70–90% of the care of sick children can be handled skillfully by trained nurses and more effective than interns and village quacks. It is also the basic philosophy of the Under-five clinics to give effective training and responsibility for handling the child health care service.

Chapter 2  Preventive Pediatrics

Table 2.2: Summary of vaccine sensitivities

Unit I  Introduction: Modern Concepts of Child Care

22 The illness care for children will comprise: z Diagnosis

and treatment of: Acute illness  Chronic illness including physical, mental congenital and acquired abnormalities  Disorders of growth and development z X-ray and laboratory services z Referral services 

Preventive Care z Immunization: Immunization is the world’s greatest public

heath tool. In the context of HFA2000, one of the health goals was to immunize the all children against the “big six” infectious diseases of childhood—diphtheria, polio, tetanus, measles, tuberculosis, whooping cough. Together these diseases kill about 5 million children in a year and disable another 5 million worldwide. z Nutritional surveillance: Almost all the nutritional disorders (i.e., PEM, anemia, rickets, etc.) occur in this age group. Nutritional surveillance is extremely important for sub clinical nutrition as it tends to be over looked. The Integrated Child Development Services (ICDS) in India has taken up supplementary feeding of children below 6 years in a big way. z Health check-ups: The health check-ups cover physical examination and appropriate laboratory tests; and are provided every 3–6 months. The child health card provides a check list for these examinations; are in use in all ICDS projects. These can be very useful in identifying ‘at risk’ children so that they can be given special attention. z Oral rehydration: On an average, child in the developing country, living in poor community suffer from an attack of diarrheal diseases between 2–6 times in a year and each time they are affected, lowers their immunity and present to the risk of death from dehydration. The home use of ORT has opened the way to the drastic reduction of child deaths and malnutrition. z Family planning: In the center of the symbol is a triangular area. If this is painted red, we have our familiar family planning triangle of India. This puts the topic in its correct context, i.e., in the center of concern for the health and well-being of the child. It is possible to conduct family planning programs through these clinics, as the mother can receive counseling about family planning. z Health education: Around the whole symbol is a border that touches all the other areas. This simply represents health education that mother automatically receives when she goes with her baby. She is taught about how to keep baby clean, and also about feeding and immunizations, etc.

Growth Monitoring This is one of the biggest activities of the under-five clinics, i.e., to weigh the child periodically every month during the

first year of life, after every 2 month during the second year and every 3 months thereafter up to the age of 5–6 years. This is plotted on growth chart against his/her age (gives what is known as the growth curve); which indirectly helps to detect early onset of growth failure (can be failure of breast feeding, intestinal parasites, etc.).

Functions of Under-Five Clinics z Registration

of all infants and toddlers and preparation of specific card. z Medical check-up on scheduled visits, at least once by medical officer. z Regular recording of health data; height, weight to verify normal growth and development. z Distribution of nutritional supplements (Vitamin-A, folic acid, etc.). z Immunization. z Reporting of all registered children to the health assistant so that he may update his vital statistics records. z Early detection of communicable/non-communicable or congenital diseases and defects. z Referral to specialists. z Training to mothers regarding child rearing, feeding and mother craft. z Advice about family planning. z Health education on various related topics. The aim of preventive pediatrics is to prevent the occurrence of diseases and promote the optimum growth and development of children so that they become productive members of the society. It encompasses antenatal care, exclusive breastfeeding, immunization, early detection of warning signs and ageappropriate counselling of adolescents.

CHILD MORBIDITY AND MORTALITY Morbidity rates and mortality rates are two health status indicators of the population. It is important to know the patterns of morbidity and mortality in children to formulate appropriate policies for intervention. Morbidity (meaning “sick, unhealthy”) is a diseased state, disability, or poor health due to any cause. The term may be used to refer to the existence of any form of disease, or to the degree that the health condition affects the patient. Morbidity rate is the number of disease prevalence of a particular disease at a given time in a stated number of population. Morbidity rates may include: z Incidence

and prevalence rates z Attendance rates and outpatient departments, health centers, etc. z Admission, readmission and discharge rates z Duration of stay in hospital z Spells of sickness or absence from work or school z Notification

23

Indicator

Definition

Neonatal mortality rate

Number of deaths among all live births during the first 28 days of life expressed per 1000 live births.

Early neonatal mortality rate

Number of neonatal deaths 95%, avoid bag and mask ventilation (distends bowel), auscultate breath sounds bilaterally.

• Respiratory support • Infection prevention • Fluid therapy • Pain management • Skin care • GI decompression • Nutrition – gastrostomy feedings, TPN

Figure 17.18: Inguinal hernia

Incarcerated Hernia Incarcerated hernia occurs when the descended portion of the bowel becomes tightly caught in the hernial sac, compromising blood supply. It is a medical emergency requiring surgical repair. Child may present with irritability, tenderness at site, anorexia, abdominal distention, and difficulty defecating. The protrusion cannot be reduced, and complete intestinal obstruction and gangrene may occur.

Hydrocele Hydrocele refers to presence of abdominal fluid in the scrotal sac (Fig. 17.19). It is of two types: non-communicating and communicating (Table 17.3). A hydrocele usually goes away on its own within six to twelve months of age. If the hydrocele does not resolve on its own, then surgical repair is needed to prevent further complications. The surgery to remove a hydrocele (hydrocelectomy) is done under general or regional anesthesia. An incision is made in the scrotum or lower abdomen to remove the hydrocele. Postoperative Interventions for hernia and hydrocele is described in Table 17.4.

271

Etiology

Figure 17.19: Hydrocele

Any kind of congenital malformation can lead to anorectal malformation. Anorectal malformation may be seen with some of these genetic syndromes or congenital problems, i.e., VACTERL association, digestive system abnormalities, urinary tract abnormalities or abnormalities of the spine.

Pathophysiology

Table 17.3: Types of hydrocele Non-communicating hydrocele

Communicating hydrocele

• It occurs when residual peritoneal fluid is trapped in the scrotum with no communication to the peritoneal cavity. • It usually disappears by age 1, as the fluid is reabsorbed.

• It is associated with a hernia that remains open from the scrotum to the abdominal cavity. • Assessment: A bulge in the inguinal area or the scrotum that increases with crying or straining and decreases when the infant is at rest. Parents may also report the bulge is smaller in the morning but increases in size throughout the day.

Table 17.4: Postoperative interventions for hernia and hydrocele

The anus and rectum originate from the embryological structure cloaca. Lateral growth of cloaca forms the urorectal septum that separates the rectum dorsally from the urinary tract ventrally. The rectum and urinary tract separate completely by the 7th week of gestation. Anomalies occur when separation fail to occur. With an anorectal malformation, several abnormalities can occur, including the following: z The anal passage may be narrow z A membrane may be present over the anal opening z The rectum may not connect to the anus z The rectum may connect to part of the urinary tract or the reproductive system through a passage called a fistula The treatment for the malformation depends on the type of abnormality present.

Signs and Symptoms z Abdominal

distension, vomiting opening very near the vagina z Baby does not pass first stool within 24–48 hours after birth z Missing or moved opening to the anus z Meconium passes out of the vagina, base of penis, scrotum, or urethra

Hernia

Hydrocele

z Anal

• Monitor vital signs • Assess for wound infection • Monitor for redness or drainage • Monitor input and output and hydration status • Advance the diet as tolerated • Administer analgesics as prescribed

• Provide ice bags a scrotal support to relieve pain and swelling • Instruct the parents that tub bathing needs to be avoided until the incision heals • Instruct the parents that strenuous physical activities need to be avoided • Advise parent that the scrotum may not immediately return to normal size

Classification of Anorectal Malformations (ARM)

ANORECTAL MALFORMATION

Wingspread classification (Table 17.5) was established in 1984 according to the level of the arrest of rectal descent and patient’s sex. Peña proposed a classification in 1995 (Table 17.6) based on the presence and position of the fistula. The position of the fistula was used to determine operative management. Male and female anomalies are shown in Figures 17.20 and 17.21 respectively.

Definition

Description of Anomalies

Malformations that occur congenitally due to abnormal development of genitourinary and pelvic organs are called

z Perineal

fistula: When rectum opens into perineum, Low malformation

Chapter 17  Gastrointestinal Disorders

anorectal malformations. With this defect, the anus and rectum do not develop properly. ARM encompasses multiple congenital anomalies of the rectum, urinary and reproductive structures with varying degree of complexity. Most children with ARM have abnormal communication with rectum, GU tract and perineum called fistulas.

Unit VII  Disease Conditions–I

272 Table 17.5: The wingspread conference classification, 1984 Level of anomaly High

Intermediate

Male Anorectal agenesis • Rectovaginal fistula • Without fistula • Rectal atresia Rectourethral fistula Anal agenesis without fistula

Low

• Anocutaneous (perineal) fistula • Anal stenosis (perineal) fistula

Miscellaneous

• Rare malformations

Female Anorectal agenesis • Rectovaginal fistula • Without fistula • Rectal atresia • Rectovestibular fistula • Rectovaginal fistula • Anal agenesis without fistula • Anovestibular (perineal) fistula • Anocutaneous • Anal stenosis • Persistent cloacal anomaly • Rare malformations

Table 17.6: Pena classification, 1995 Males Perineal fistula Rectourethral fistula  Bulbar  Prostatic Rectovesical fistula

Imperforate anus without fistula Rectal atresia

Female Perineal fistula Vestibular fistula

Persistent cloaca  3 cm common channel Imperforate anus without fistula Rectal atresia

Figure 17.20: Anomalies in males

273 Chapter 17  Gastrointestinal Disorders

Figure 17.21: Anomalies in females z Rectourethral bulbar fistula:

Rectum communicates with the lower posterior portion of the urethra called bulbar urethra. z Rectourethral prostatic fistula: Rectum communicates with the upper part of the posterior portion of the urethra passing through prostatic tissue z Rectobladder neck fistula: Highest defect in male. Rectum communicates with bladder neck. There is abnormal sacrum. z Imperforate anus without fistula: Rectum is completely blind, ends 2 cm from perineum. No meconium in urine. It is associated with Down syndrome. z Vestibular fistula: Rectum opens through an abnormally narrow orifice located in the vestibule of the genitalia, outside the hymen z Vaginal fistula: Meconium comes out through the vagina from inside the hymen orifice z Persistent cloaca: Rectum, vagina and urinary tract are fused together into a single common channel that communicates exteriorly through a single perineal orifice located at normal urethral site

z Cloacal

exstrophy: It is a rare malformation and includes omphalocele, 2 exstrophied hemi bladders with cecum between them, imperforate anus and abnormal sexual structures

Diagnosis z Physical

assessment: Check the patency of anus and rectum. Rectourinary fistula is suspected if there is meconium in the urine z Abdominal ultrasound: To determine the existence of other malformation z Intravenous pyelogram and cystourethrogram: For patients with high malformations to identify anomalies of urinary tract. z Invertogram: To assess height of defect

Management The treatment of an anorectal malformation may depend on the extent of the problem and the overall health of the child

Unit VII  Disease Conditions–I

274 and medical history. The type and number of operations necessary depend on the type of abnormality the infant has, including the following: z Low defects or perineal fistulas or imperforate anus: Anoplasty: Infant is kept NPO for 4 hours. Fistula is moved to anatomically correct position, at the center of anal sphincter. Larger anal opening is created. Nothing is inserted in rectum. Antibiotic ointment is applied on perineum TDS for 2 weeks. Administer IV antibiotics for 2–3 days. Continue breastfeeding. Anal dilatations at 2 weeks. z Lack of rectal/anal connection, with or without a fistula: These infants need a series of operations in order to have the malformation repaired. First, a surgery is done to create a colostomy. With a colostomy, the large intestine is divided into two sections and the ends of intestine are brought through openings in the abdomen. The upper section allows stool to pass through a stoma and then into a collection bag. The lower section allows mucus that is produced by the intestine to pass into a collection bag. Colostomy does not impair the digestion of child and he/she can grow before time for the next surgery. Also, when the next surgery is done on the lower section of intestine, there will not be any stool present to infect the area. Care of the colostomy is important during this time. Posterior Sagittal Anorectoplasty (PSARP): This attaches the rectum to the anus and is usually done within the first few months of life. The colostomies remain in place for a few months after this operation so the area can heal without being infected by stool. Even though the rectum and anus are now connected, stool will leave the body through the colostomies until they are closed with surgery. A few weeks after surgery, parents may be performing anal dilatations to help the child get ready for the next phase. Two to three months later, an operation is done to close the colostomies. The child is not allowed anything to eat for a few days after surgery while the intestine is healing. Several days after surgery, the child will start passing stools through the rectum. At first, stools will be frequent and loose. Diaper rash and skin irritation can be a problem at this stage. Within a few weeks after surgery, the stools become less frequent and more solid, often causing constipation. A high-fiber diet can be provided to manage constipation.

Toilet training should be started at the usual age, which is generally when the child is between two and three years old. However, children who have had anorectal malformations repaired may be slower than others to gain bowel control. Some children may not be able to gain good control over their bowel movements, while others may be chronically constipated, depending on the type of malformation and its repair.

Nursing Management z Assessment

of the child immediately after birth. if the child has passed stools after 24 hours of birth. z For children who have undergone anoplasty, provide frequent dressing change. z Provide side-lying position with hips extended or supine position with legs extended at 90 degrees. z Administer perineal care to the child. z For children with colostomy, perform frequent dressing change and meticulous skin care. Assess stoma for infection or any other complications. z Check

HEPATITIS Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, alcohol, a medication reaction, or another disease process.

Types Hepatitis A, B, C, D, E, G Causative organism of hepatitis is Hepatitis virus (A, B, C, D, E, and G), CMV, EB Virus, Herpes Simplex virus, Varicella zoster, enterovirus, adenovirus, and parvovirus.

Mode of Transmission (Table 17.7) z Feco-oral

route: No hand washing, eating contaminated food or drinks z Parenteral: Razors, needle stick injury, blood transfusions z Sexual z Perinatal: Mother to baby

Symptoms A child with hepatitis will exhibit flu like symptoms to pallor, nausea, vomiting, dark colored urine and clay colored stools.

Table 17.7: Types and mode of transmission of hepatitis Mode of Transmission

Type A

Type B

Type C

Type D

Type E

Type G

Feco-oral route

Parenteral route— Needle stick injury Perinatal Sexual—blood, body fluids

Parenteral Perinatal Sexual

It only happens with hepatitis B

Feco-oral route

Parenteral

275

Diagnosis can be established in case there is elevated liver enzymes, prolonged PT, hyperbilirubinemia and lower serum albumin level. Other tests which can be done are LFT, U/S, MRI, CT scan and Liver Biopsy.

Complications Liver failure and hepatocellular carcinoma

Management Supportive, Antivirals, Liver transplant

Prevention Vaccination is available for Hepatitis B.

Hepatitis A Hepatitis is a self-limited disease. It has only acute phase. z Mode of Transmission is a feco-oral route. Viral replication occurs in the liver, leading to hepatic injury. Liver injury is represented in three ways: 1. Direct cellular injury that elevates serum liver enzyme levels 2. Cholestasis that causes jaundice and hyperbilirubinemia 3. Inadequate liver function z S/S: The patient’s initial symptoms during the prodromal period include low-grade fever, nausea, vomiting, decreased appetite, and abdominal pain. Older children are more likely to report pain in the right upper quadrant. z Diagnosis: Elevated alanine aminotransferase (ALT), aspartate aminotransferase (AST), increased bilirubin, lower serum albumin levels and prolong PT

Nursing Interventions z Enforce

strict hand washing. z Hospitalization is required if there is evidence of coagulopathy or fulminant hepatitis. z Follow standard precautions and enteric precautions during hospitalization. z Provide enteric precautions for at least 1 week after the onset of jaundice with HAV. z The hospitalized child usually is not isolated in a separate room unless he or she is fecally incontinent and items are likely to become contaminated with feces. z Children are discouraged from sharing toys. z Instruct the parents to disinfect diaper-changing surfaces thoroughly with bleach solution. z Maintain comfort and provide adequate rest and sleep. z Provide a low-fat, well-balanced diet. z Inform the parents that because HAV is not infectious 1 week after the onset of jaundice, the child may return to school at that time if he or she feels well enough.

z Inform

the parents that jaundice may appear worse before it resolves. z Instruct the parents about the signs of worsening child’s condition, changes in neurological status, bleeding, and fluid retention.

Hepatitis B Most HBV infection in children is acquired perinatally. Newborns are at risk if the mother is infected with HBV or was a carrier of HBV during pregnancy. Possible routes of maternal-fetal (newborn) transmission is leakage of the virus across the placenta late in pregnancy or during labor, ingestion of amniotic fluid or maternal blood, and breastfeeding, especially if the mother has cracked nipples. The severity in the infant varies from no liver disease to fulminant (severe acute course) or chronic active disease. HBV infection occurs in specific high-risk groups, i.e.,: z Children

with hemophilia or other disorders requiring multiple blood transfusions z Children or adolescents involved in IV drug abuse, institutionalized children, preschool children in endemic areas z Children who are involved in sexual activity Infection with HBV can cause a carrier state and lead to eventual cirrhosis or hepatocellular carcinoma in adulthood. Clinicopathologic syndromes include the following: z Acute asymptomatic infection with recovery: Child is asymptomatic and there is serologic evidence of infection z Acute hepatitis with resolution: It consists of anicteric or icteric phase (Table 17.8) z Chronic hepatitis, with or without progression to cirrhosis z Fulminant hepatitis with massive liver necrosis z Coinfection with hepatitis D virus (hepatitis delta virus)

Diagnosis z Detection

of immunoglobulin M (IgM) which denotes active infection and IgG which denotes past infection.

Table 17.8: Phases of hepatitis Prodromal or anicteric phase

Icteric phase

• Lasts 5–7 days • Absence of jaundice • Anorexia, malaise, lethargy, easy fatigability • Fever (especially in adolescents) • Nausea and vomiting • Epigastric or right upper quadrant abdominal pain • Arthralgia and rashes (more likely with hepatitis B virus) • Hepatomegaly

• Jaundice, which is best assessed in the sclera, nail beds, and mucous membranes • Dark urine and pale stools • Pruritus

Chapter 17  Gastrointestinal Disorders

Diagnosis

Unit VII  Disease Conditions–I

276 z Hepatitis

B – HBsAg and antibody + , Hepatitis B DNADNA PCR z Liver biopsy

Medical Management Antiviral agents: Tenofovir, Lamivudine

Prevention for Hepatitis B z Follow

standard precautions.

z Wear gloves while touching bandages, tampons, and linens. z Cover

all open cuts or wounds. share razors, toothbrushes, nail care tools, or pierced earrings with anyone. z Make certain that any needles for drugs, ear piercing, or tattoos – or tools for manicures and pedicures – are properly sterilized. z Clean up blood with one part household bleach and 10 parts water. z Educate for safe sex practices z Screening for blood donation z Don’t

Vaccination z Hepatitis

A vaccine and hepatitis B vaccine B vaccine is given at 0, 1, 6 months, I/M, 0.5 mL. Vaccine uses hepatitis B surface antigen (HbsAg) to stimulate the production of antibodies in noninfected individuals (active immunity). z PEP- Hepatitis B Ig provides passive immunity and may be effective in preventing infection after a 1-time exposure (should be given immediately after exposure), such as an accidental needle puncture or other contact of contaminated material with mucous membranes; immunoglobulin should also be given to newborns whose mothers are positive for hepatitis B surface antigen. z Hepatitis

z Provide

information to the parents about enzyme tablets that predigest the lactose in dairy products or supplement the body’s own lactase. z Substitute soy-based formulas for cow’s milk formula or human milk. z Allow milk consumption as tolerated. z Instruct the child and family that the child should drink milk with other foods z Encourage consumption of hard cheese, cottage cheese, and yogurt, which contain the inactive lactase enzyme. z Encourage consumption of small amounts of dairy foods daily to help colonic bacteria adapt to ingested lactose. z Instruct the parents about the foods that contain lactose, including hidden sources. z A child with lactose intolerance can develop calcium and vitamin D deficiency. Instruct the parents about the importance of providing these supplements.

MALABSORPTION SYNDROME Malabsorption syndrome refers to a number of disorders in which the small intestine cannot absorb enough of certain nutrients and fluids. These may include proteins, carbohydrates, and fats, micronutrients (vitamins and minerals), or both.

Causes

Lactose intolerance is defined as inability to tolerate lactose due to absence or deficiency of lactase, an enzyme found in the secretions of the small intestine that is required for the digestion of lactose.

Factors that may cause malabsorption syndrome include: z Damage to the intestine from infection, inflammation, trauma, or surgery z Prolonged use of antibiotics z Other conditions such as celiac disease, Crohn’s disease, chronic pancreatitis, or cystic fibrosis z Lactase deficiency, or lactose intolerance z Congenital defects such as biliary atresia z Diseases of the gallbladder, liver, or pancreas z Parasitic diseases z Radiation therapy, which may injure the lining of the intestine z Certain drugs that may injure the lining of the intestine, such as tetracycline, colchicine, or cholestyramine

Assessment

Symptoms

z Symptoms

Symptoms are related to deficiency of absorption of following nutrients: z Fats: Light-colored, foul-smelling stools that are soft and bulky. Stools are difficult to flush and may float or stick to the sides of the toilet bowl. z Protein: Dry hair, hair loss, or fluid retention. z Bloating, gas, or explosive diarrhea. z Certain vitamins: Anemia, malnutrition, low blood pressure, weight loss, or muscle wasting.

LACTOSE INTOLERANCE Definition

occur after the ingestion of milk or other dairy products. z Abdominal distention z Crampy, abdominal pain; colic z Diarrhea and excessive flatus

Interventions z Eliminate the dairy product which is causing symptoms, or

administer an enzyme tablet replacement.

277 may stop menstruating, and children may not grow properly. Their weight or rate of weight gain may be significantly below that of other children of a similar age and gender.

Diagnosis z Stool

tests to measure fat. tests to measure the level of specific nutrients such as vitamin B-12, vitamin D, folate, iron, calcium, carotene, phosphorus, albumin, and protein. z Biopsy of small intestine. z Imaging tests to look for structural problems of small intestine z Blood

Treatment z Treatment

is supportive based on the findings. may be administered for diarrhea z Monitor for signs of dehydration, like increased thirst, low urine output, and dry mouth, skin, or tongue. z In case of lactose intolerance, advise to avoid milk and other dairy products or take a lactase enzyme tablet. z Enzyme supplements to help body absorb the nutrients z Vitamin supplements z Loperamide

CELIAC DISEASE Celiac disease is also known as gluten enteropathy or celiac sprue. There is intolerance to gluten, the protein component of wheat, barley, rye, and oats. There is accumulation of the amino acid glutamine, which is toxic to intestinal mucosal cells. Intestinal villous atrophy occurs, which affects absorption of ingested nutrients. Symptoms of the disorder occur most often between the ages of 1 and 5 years. There is usually an interval of 3 to 6 months between the introduction of gluten in the diet and the onset of symptoms. Strict dietary avoidance of gluten minimizes the risk of developing malignant lymphoma of the small intestine and other GI malignancies.

Interventions z Maintain

a gluten-free diet, substituting corn, rice, and millet as grain sources. z Instruct the parents and child about lifelong elimination of gluten sources such as wheat, rye, oats, and barley. z Administer mineral and vitamin supplements, including iron, folic acid, and fat-soluble vitamins A, D, E, and K. z Teach the child and parents about a gluten-free diet and about reading food labels carefully for hidden sources of gluten.

APPENDICITIS Appendicitis is inflammation of the appendix. When the appendix becomes inflamed or infected, perforation may occur within hours, leading to peritonitis, sepsis, septic shock, and potentially death. Treatment is surgical removal of the appendix before perforation occurs.

Assessment z Pain

in periumbilical area that descends to the right lower quadrant z Abdominal pain that is most intense at McBurney’s point (Fig. 17.22). z Referred pain indicating the presence of peritoneal irritation z Rebound tenderness and abdominal rigidity z Elevated white blood cell count z Side-lying position with abdominal guarding (legs flexed) to relieve pain z Difficulty in walking and pain in the right hip

Assessment z Acute

or insidious diarrhea

z Steatorrhea z Anorexia

z Abdominal

pain and distention

z Muscle wasting, particularly in the buttocks and extremities z Vomiting z Anemia

z Irritability

z Celiac crisis is precipitated by fasting, infection, or ingestion

of gluten. There is profuse watery diarrhea and vomiting. It can lead to rapid dehydration, electrolyte imbalance, and severe acidosis.

Figure 17.22: McBurney’s point

Chapter 17  Gastrointestinal Disorders

z Women

Unit VII  Disease Conditions–I

278 Postoperative Interventions

z Low-grade z Anorexia, z Diarrhea

fever nausea, and vomiting after pain develops

z Monitor

vital signs, especially temperature.

z Maintain NPO status until bowel function returns, advance

Complication Peritonitis: It can result from a perforated appendix. There is increased fever, progressive abdominal distention, tachycardia and tachypnea, pallor, chills, restlessness and irritability. An indication of a perforated appendix is the sudden relief of pain and then a subsequent increase in pain accompanied by right guarding of the abdomen.

Surgical Management Appendectomy: It refers to removal of appendix

Preoperative Care z Maintain

NPO status. IV fluids and electrolytes as prescribed to prevent dehydration and maintain electrolyte balance. z Monitor for changes in the level of pain. z Monitor for signs of a ruptured appendix and peritonitis. z Avoid the use of pain medications so as not to mask pain changes associated with perforation. z Administer antibiotics as prescribed. z Monitor bowel sounds. z Position in a right side-lying or low to semi-Fowler’s position to promote comfort z Apply ice packs to the abdomen for 20 to 30 minutes every hour if prescribed. z Avoid the application of heat to the abdomen. z Avoid laxatives or enemas z Administer

the diet gradually as tolerated and as prescribed when bowel sounds return. z Assess the incision for signs of infection, redness, swelling, drainage, and pain. z Monitor drainage from the drain, which may be inserted if perforation occurred. z Position the child in a right side lying or low to semiFowler’s position with the legs slightly flexed to facilitate drainage. z Change the dressing as prescribed and record the type and amount of drainage. z Perform wound irrigations if prescribed. z Maintain NG tube suction and patency of the tube if present. z Administer antibiotics and analgesics as prescribed.

WORM INFESTATION Common infections in children are giardiasis and pinworm infestation. Giardiasis is caused by protozoa and is prevalent among children in crowded environments, such as classrooms or day care centers. Mode of transmission is feco-oral route (soil, water). It is caused by Giardia intestinalis, Giardia lamblia, or Giardia duodenalis), found on surfaces or in soil, food, or water that has been contaminated with feces) from infected humans or animals. Stool specimens from three or more collections are used for diagnosis. Giardiasis and Pinworm infestation are explained in Table 17.9.

Table 17.9: Overview of worm infestations Giardiasis

Pinworms

Causative organism

Giardia intestinalis, Giardia lamblia, or Giardia duodenalis

A small, thin, white roundworm (nematode) called Enterobius vermicularis

Symptoms

• Diarrhea and vomiting • Anorexia • Failure to thrive • Abdominal cramps with intermittent loose stools and constipation • Steatorrhea

• Intense perianal itching • Irritability, restlessness • Poor sleeping • Bed wetting

Management • Medications are not usually prescribed for children younger than 2 years. • Drugs, metronidazole, tinidazole, and nitazoxanide • Caregivers should wash hands meticulously. • Provide education to family and caregivers regarding sanitary practices.

• Perform a visual inspection of the anus with a flashlight 2 to 3 hours after sleep. • The tape test is the most common diagnostic test. • Educate the family and caregivers regarding the tape test. A loop of transparent tape is placed firmly against the child’s perianal area; it is removed in the morning and placed in a glass jar or plastic bag and transported to the laboratory for analysis. • All members of the family are treated for the infection. • Teach the family and caregivers about the importance of meticulous hand washing and about washing all clothes and bed linens in hot water. • Deworming, either mebendazole (500 mg), pyrantel pamoate, or albendazole (400 mg). Any of these drugs are given in one dose initially, and then another single dose of the same drug two weeks later.

279

The red flags for children with GI system disorders include abdominal pain, vomiting, weight gain or weight loss, bloody stools, constipation, diarrhea, fever, fistulas, oral ulcers, etc. Treating GI disorders involve plenty of rest, medicines, maintaining hydration, BRAT (bananas, rice, applesauce and toast) diet, and avoiding spices. Sometimes surgery may be needed.

Assess Yourself 1. Name the surgeries done for: • Cleft lip ……………… • Cleft palate ……………. • Pyloric stenosis ……………. • GERD………………… • Megacolon ………………

• Choledochal cyst …………………. • High ARM ……………. 2. Full form of VACTERL syndrome is ………………. 3. List the preventive strategies for transmission of Hepatitis. 4. Pain in McBurney’s point is seen in ……………………

Chapter 17  Gastrointestinal Disorders

Summary

Chapter

18

Nutritional Disorders Chapter Outline  Introduction  Malnutrition

 Eating Disorders

 Vitamin Deficiency Disorders

INTRODUCTION Health and nutritional status of an individual depend on the food he eats. The quality, quantity, and frequency of food is important. Nutritional status refers to the state of health of an individual as it is affected by the intake and utilization of nutrients. Essential nutrients needed by our body are Proteins, Fats, Carbohydrates, Fiber, Vitamins, Minerals and Water. Main nutritional disorders in children include: Obesity, Starvation, Kwashiorkor, Marasmus, Anorexia nervosa, Bulimia nervosa, Vitamin deficiency, and Trace element deficiency.

MALNUTRITION The World Health Organization (WHO) defines malnutrition as, “the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions.” Malnutrition is a range of conditions occurring when intake of one or more nutrients doesn’t meet the requirements. It includes both undernutrition and obesity. Undernutrition can be classified as underweight, stunted or wasted (Fig. 18.1). z Underweight:

Low Weight for Age z Stunted: Low Height for Age z Wasted: Low Weight for Height

Figure 18.1: Types of undernutrition

Causes of Malnutrition Malnutrition can be caused by inadequate food intake, illiteracy, poor eating habits, ineffective weaning practices, low family income, economic and cultural causes, poor hygiene, recurrent infections and poor lifestyle choices.

Nutritional Assessment Nutritional assessment is needed to: z Identify early, at risk individuals for malnourishment z Identify malnourished individuals z Develop health care plans for malnourished individuals.

Methods of Nutritional Assessment

18

Table 18.2: WHO classification of weight status as per BMI

Nutritional assessment can be done with ABCD method, i.e., Anthropometric measurement, Biochemical parameters, Clinical examination and Dietary survey.

Weight status

Body mass index (BMI), kg/m2

Underweight

30

 Obese class I

30.0–34.9

 Obese class II

35.0–39.9

 Obese class III

>40

Table 18.1: Weech’s formula for expected weight Age

Expected weight (kg)

3–12 months

age (months) + 9/2

1–6 years

age (years) × 2 + 8

7–12 years

age (years) × 7–5/2

WHO classification of weight status

Table 18.3: Interpretation of mid-upper arm circumference (MUAC) Color coding MUAC

Interpretation

Red

0–11.5 cm

Severe acute malnutrition (SAM)

Yellow

11.5–12.5 cm

Moderate malnutrition

Green

12.5–26.5 cm

Well nourished

status (Table 18.3). Arm circumference does not change much between 1–5 years of age. MUAC is an easy and useful measure for assessing the thickness or muscle wasting in children in the age group of 1–5 years. Malnourished children are referred to Nutrition Rehabilitation Center (NRC). z Head circumference (HC): Infants have a large head at birth as compared to the rest of the body. HC can be measured with an ordinary tape.  At birth it is 33–35 cm which is 3 cm greater than chest circumference.  Head circumference increases 2 cm per month from birth to 3 months, 1 cm/month from 4–6 months and 0.5 cm/month for next 6 months.  Average HC at 6 months is 43 cm and at 12 months it is 46 cm.  Closure of cranial sutures takes place with posterior fontanel fusing at 6–8 weeks of age and anterior fontanel fusing by 12–18 months of age. z Chest circumference: At birth the circumference of chest is about 3 cm less than head circumference. Head circumference and chest circumference equals by end of first year. z Skin fold thickness: Harpenden and Lange callipers are used to assess the skinfold thickness, as a measure for subcutaneous fat. Areas commonly measured are biceps, triceps, subscapular and suprascapular. When there is insufficient intake of calories for over a long period of time, the skin fold thickness reduces thus indicating undernutrition. Triceps skin fold is the most representative of the total subcutaneous fat up to sixteen years of age. It is usually above 10 mm in normal children whereas in severely malnourished it may fall below 6 mm.

Chapter 18  Nutritional Disorders

er

281

Unit VII  Disease Conditions–I

282 Biochemical Measurement

Dietary Survey

In a complete nutritional assessment, it may be useful to screen the biochemical parameters like albumin, prealbumin, CRP, transferrin, hemoglobin, urea and creatinine and lymphocytes.

It is a systematic survey into the food consumption of population/individual. It includes 24 hours dietary recall, food frequency questionnaire and dietary history. 24 hour recall: Interviewer asks the child to recall all food and drinks taken in the previous 24 hours (Table 18.5). Dietary history: Details about usual intake, type, amount, frequency, preferences, allergies, etc. (Table 18.6). Food diary: Individual is asked to maintain a food diary for 1–7 days.

z Albumin:

It is useful because decreasing albumin concentration is a sign of an inflammatory reaction. An increasing albumin level can be interpreted as an improvement; the patient becomes anabolic. The albumin level only increases when the inflammation decreases. z Creatinine: It is used to get an impression of the quantity of muscle mass. When the kidney works well, a decreased creatinine can indicate decreased muscle mass. z CRP: CRP can increase up to a thousand times as a reaction to inflammation, sepsis or infection. It can be used to monitor stress response during the acute phase. z Hemoglobin: Hb decreases very fast during illness. z Lymphocytes: The total lymphocytes count is not a sensitive index for malnutrition, because it reacts very slowly to recovery from malnutrition. The total amount of lymphocytes can increase in case of inflammation, radiation therapy and chemotherapy.

Clinical Method It involves looking for clinical sign and symptoms indicative of particular deficiency (Table 18.4).

Protein Energy Malnutrition Protein energy malnutrition (PEM) is a global issue, seen primarily in resource-limited countries. Overall, malnutrition has decreased worldwide, but the rates vary by region. For example, Asia has seen declines in this condition, whereas there has been a continued increase in African nations. PEM refers to a group of related disorders that include marasmus, kwashiorkor, and intermediate states of marasmuskwashiorkor. Malnutrition can be classified as acute versus chronic. Features of chronic malnutrition include stunted growth, mental apathy, developmental delay, and poor weight gain. Acute malnutrition manifests itself in two major forms: marasmus (the most common form) and kwashiorkor, although some patients’ condition may manifest as a

Table 18.4: Signs and symptoms to assess deficiency Sl. no.

Areas

Signs

1.

General activity

Lethargic/active

2.

Hair

Shiny/loss of luster/sparse and thin/discolored/easily plucked/flag sign

3.

Face

Moon face/buccal fat pad

4.

Eyes

Nightblindness/photophobia/ Pigmentation of the conjunctiva-brown/conjunctival xerosis/bitot’s spots/corneal xerosis/keratomalacia angular conjunctivitis/pale conjunctiva/yellow sclera

5.

Mouth

Glossitis/bleeding and spongy gums/ angular stomatitis/cheilosis/sore mouth and tongue/leukoplakia

6.

Teeth

Caries/mottled enamel

7.

Glands

Goiter

8.

Skin

Pallor/follicular hyperkeratosis/flaky dermatitis/pigmentation/desquamation/ bruising/purpura/ Grazy-pavement dermatosis Tenting of skin Edema

9.

Nails

Spooning of the nails, brittle nails/transverse lines

10.

Limbs

Baggy pants appearance

11.

GI system

Diarrhea, constipation

12.

Joints and bones

Cranial bossing frontal/parietal/beading of ribs/knock knees/bow legs

13.

Nervous system

Numbness and tingling of extremities/burning feet/tenderness of calf muscles/loss of knee/ankle jerks

Observation

283

Time

Food items

Amount

Remarks

Amount Consumed

Calories

Early morning Breakfast Mid-Morning Afternoon Post lunch Tea time Evening Dinner Post dinner

Table 18.6: Food intake history (Daily) Time

Food

Breakfast Snacks Lunch Snacks Dinner Total

combination of both forms (marasmic kwashiorkor). Children with kwashiorkor have nutritional edema and metabolic disturbances, including hypoalbuminemia and hepatic steatosis, whereas marasmus is characterized by severe wasting.

Factors Associated with Protein Energy Malnutrition z Low

birth spacing antenatal and postnatal care z Wrong feeding practices: Inadequate food intake, ineffective weaning secondary to ignorance z Congenital anomalies that prevent the infant taking adequate diet. z Disease condition that interferes with assimilation of food. z Food allergies. z Infections: Gastrointestinal infections can precipitate clinical PEM because of associated diarrhea, anorexia, z Poor

vomiting, increased metabolic needs, and decreased intestinal absorption. Parasitic infections can lead to malnutrition. Immature immune systems causing a greater susceptibility to infection, and exposure to nonhygienic conditions. z Literacy: Lack of knowledge about good feeding practices and hygiene among caregivers. z Socioeconomic status of family: Less family income leading to inadequate provision of food to children.

Pathophysiology Marasmus occurs when there is an insufficient energy (calories) intake to match the body’s requirements. As a result, the body draws on its own stores, resulting in emaciation. In kwashiorkor, adequate carbohydrate consumption and decreased protein intake lead to decreased synthesis of visceral proteins (albumin). The resulting hypoalbuminemia

Chapter 18  Nutritional Disorders

Table 18.5: Assessment criteria for 24-hour recall

Unit VII  Disease Conditions–I

284 contributes to extravascular fluid accumulation. Impaired synthesis of B-lipoprotein produces a fatty liver. PEM involves an inadequate intake of many essential nutrients. Low serum levels of zinc have been implicated as the cause of skin ulceration in many patients.

Diagnosis

Classification of Protein Energy Malnutrition

Obtain a detailed dietary history, growth measurements, body mass index (BMI), as well as perform a complete physical examination. Sensitive measures of nutritional deficiency in children include the following:

The classification of PEM is shown in Tables 18.7A and 18.7B. The classification is done based on Weight for age, Height for age and Weight for height. Formula to calculate weight for age % for Gomez classification Weight for age (%) = (weight of the child/weight of normal child of same age) × 100

Diagnosis of PEM can be confirmed with detailed history, physical examination and lab work.

History

z Height-for-age

measurements that are