Table Of Content

Eighth Edition Contents Preface to the Eighth Edition Preface to the First Edition List of Contributors 1. Introduction to Pediatrics Vinod KPaul Pediatrics as a specialty Health system in India 2 National programs on child health 3 vii ix xi 2. Normal Growth and its Disorders 7 Ramesh Agarwal, Naveen Sankhyan, Vandana Jain Somatic growth 11 Assessment of physical growth 11 Disorders of growth 35 Abnormalities of head size and shape 39 3. Development 42 Ramesh Agarwal, Vandana Jain, Naveen Sankhyan Normal development 42 Behavioral disorders 57 Habit disorders and tics 59 4. Adolescent Health and Development Tushar R Godbole. Vijayalakshmi Bhatia Physical aspects 63 Cognitive and social development 63 Problems faced by adolescents 65 Role of health care provider 67 5. Fluid and Electrolyte Disturbances Kamran Afzal Composition of body fluids 70 Deficit therapy 72 Sodium 73 Potassium 76 Calcium 79 Magnesium 82 Acid-base disorders 83 6. Nutrition Vinod K Paul, Rakesh Lodha, Anuja Agarwala Macronutrients 88 Normal diet 90 Undernutrition 95 Management of malnutrition l 00 63 70 88 7. Micronutrients in Health and Disease Ashima Gulati, Arvind Bagga Fat soluble vitamins 110 Water soluble vitamins 117 Minerals and trace elements 121 110 8. Newborn Infants 124 Ramesh Agarwal, Vinod K Paul, Ashok K Deorari Resuscitation of a newborn 125 Routine care 133 Thermal protection 143 Fluid and electrolyte management 146 Kangaroo mother care 148 Breastfeeding 150 Care of low birth weight babies 155 Infections in the neonates 162 Perinatal asphyxia 166 Respiratory distress 168 Jaundice 172 Congenital malformations 176 Followup of high risk neonates 178 Metabolic disorders 179 Effect of maternal conditions on fetus and neonates 181 9. Immunization and Immunodeficiency 184 Aditi Sinha, Surjit Singh Immunity 184 Primary immunodeficiency disorders 185 Immunization 188 Commonly used vaccines 190 Vaccine administration 203 Immunization programs 205 Immunization in special circumstances 206 10. Infections and Infestations Tanu Singha!, Rakesh Lodha, SK Ka bra Fever 209 Common viral infections 213 Viral hepatitis 220 Human immunodeficiency virus (HIV) 229 Common bacterial infections 240 Tuberculosis 250 Fungal infections 259 Protozoa! infections 260 Congenital and perinatal infections 272 Helminthic infestations 273 209 -.... E _ s _ s _ e _ n _ t _ ia _ l _ P _ e _ d _ ia _ t _ ri _ c _ s ________________________________ _ 11. Diseases of Gastrointestinal System and Liver 278 Anshu Srivastava, Barath Jagadisan, SK Yachha Gastrointestinal disorders 278 Acute diarrhea 291 Persistent diarrhea 297 Chronic diarrhea 299 Gastrointestinal bleeding 306 Disorders of the hepatobiliary system 309 Acute viral hepatitis 312 Liver failure 313 Chronic liver disease 316 12. Hematological Disorders Tulika Seth Anemia 330 Approach to hemolytic anemia 337 Hematopoietic stem cell transplantation 347 Approach to a bleeding child 349 Thrombotic disorders 355 Leukocytosis, leukopenia 357 13. Otolaryngology Sandeep Samant, Grant T Rohman, Jerome W Thompson Diseases of the ear 359 Diseases of the nose and sinuses 363 Diseases of the oral cavity and pharynx 366 Diseases of the larynx and trachea 368 Diseases of the salivary glands 370 14. Disorders of Respiratory System SK Kabra Common respiratory symptoms 371 Investigations for respiratory illness 373 Respiratory tract infections 374 Acute lower respiratory tract infections 376 Bronchial asthma 382 Foreign body aspiration 391 Lung abscess 391 Bronchiectasis 392 Cystic fibrosis 393 Acute respiratory distress syndrome (ARDS) 393 15. Disorders of Cardiovascular System R Krishna Kumar, R Tandon, Manu Raj Congestive cardiac failure 396 Congenital heart disease 400 Acyanotic congenital heart defects 413 Cyanotic heart disease 420 Obstructive lesions 429 330 359 371 396 Rheumatic fever and rheumatic heart disease 433 Infective endocarditis 443 Myocardial diseases 447 Pericardia! diseases 450 Systemic hypertension 451 Pulmonary arterial hypertension 456 Rhythm disorders 457 Preventing adult cardiovascular disease 462 16. Disorders of Kidney and Urinary Tract Arvind Bagga, Aditi Sinha, RN Srivastava Renal anatomy and physiology 464 Diagnostic evaluation 467 Acute glomerulonephritis 47 4 Nephrotic syndrome 477 Chronic glomerulonephritis 483 Urinary tract infections 483 Acute kidney injury 487 Chronic kidney disease 493 Renal replacement therapy 497 Disorders of renal tubular transport 497 Enuresis 504 Congenital abnormalities of kidney and urinary tract 505 Cystic kidney diseases 507 17. Endocrine and Metabolic Disorders PSN Menon, Anurag Bajpai, Kanika Ghai Disorders of pituitary gland 511 Disorders of thyroid gland 516 Disorders of calcium metabolism 521 Disorders of adrenal glands 523 Obesity 528 Disorders of the gonadal hormones 53 l Diabetes mellitus 54 l 18. Central Nervous System Veena Kalra Approach to neurological diagnosis 549 Seizures 552 Febrile convulsions 556 Epilepsy 557 Coma 561 Acute bacterial meningitis 563 Tuberculous meningitis 566 Encephalitis and encephalopathies 568 lntracranial space occupying lesions 570 Subdural effusion 573 Hydrocephalus 574 Neural tube defects 575 Acute hemiplegia of childhood 577 Paraplegia and quadriplegia 578 Ataxia 579 Cerebral palsy 581 464 510 549 ___________________________________ :c:on :.:;t::e:.:. nt:s....J- Degenerative brain disorders 583 Mental retardation 584 Neurocutaneous syndromes 586 19. Neuromuscular Disorders Sheffali Gulati Approach to evaluation 587 Disorders affecting anterior horn cells 588 Peripheral neuropathies 589 Acute flaccid paralysis 592 Neuromuscular junction disorders 593 Muscle disorders 594 20. Childhood Malignancies Sadhna Shankar, Rachna Seth Leukemia 599 Lymphoma 608 Brain tumors 612 Retlnoblastoma 614 Neuroblastoma 616 Wilms tumor 617 Soft tissue sarcoma 618 Bone tumors 619 Malignant tumors of the liver 620 Histiocytoses 620 Oncologic emergencies 622 Hematopoietic stem cell transplantation 623 21. Rheumatological Disorders Surjit Singh Arthritis 624 Systemic lupus erythematosus 628 Juvenile dermatomyositis 629 Scleroderma 630 Mixed connective tissue disease 630 Vasculitides 631 22. Genetic Disorders Neerja Gupta, Madhulika Kabra Chromosomal disorders 636 Single gene disorders 64 l Polygenic inheritance 644 Therapy for genetic disorders 644 Prevention of genetic disorders 645 23. Inborn Errors of Metabolism Neerja Gupta, Madhulika Kabra Suspecting an inborn error of metabolism 647 Aminoacidopathies 652 Urea cycle defects 653 Organic acidurias 655 Defects of carbohydrate metabolism 655 Mitochondial fatty acid oxidation defects 657 Lysosomal storage disorders 659 587 599 624 635 647 24. Eye Disorders Radhika Tandon Pediatric eye screening 665 Congenital and developmental abnormalities 666 Acquired eye diseases 667 25. Skin Disorders Neena Khanna. Seemab Rasool Basic principles 672 Genodermatoses 675 Nevi 679 Eczematous dermatitis 680 Disorders of skin appendages 682 Papulosquamous disorders 684 Disorders of pigmentation 686 Drug eruptions 686 Infections 687 Diseases caused by arthropods 694 26. Poisonings, Injuries and Accidents P Ramesh Menon Poisoning 696 Common poisonings 700 Envenomation 703 Injuries and accidents 704 27. Pediatric Critical Care Rakesh Lodha, Manjunatha Sarthi 665 672 696 708 Assessment and monitoring of a seriously ill child 708 Pediatric basic and advanced life support 71 O Shock 715 Mechanical ventilation 719 Nutrition in critically ill children 720 Sedation, analgesia and paralysis 721 Nosocomial infections in PICU 721 Transfusions 723 28. Common Medical Procedures Sidharth Kumar Sethi. Arvind Bagga Obtaining blood specimens 727 Removal of aspirated foreign body 727 Nasogastric tube insertion 728 Venous catheterization 728 Capillary blood (hell prick) 730 Umbilical vessel catheterization 730 Arterial catheterization 731 lntraosseous Infusion 731 Lumbar puncture 732 Thoracocentesis 733 Abdominal paracentesis or ascitic tip 734 Catheterization of bladder 734 Peritoneal dialysis 734 Bone marrow aspiration and biopsy 736 Liver biopsy 737 Renal biopsy 738 727 ___ E _ s _ s _ e _ n _ ti _ a _ i _ Pe _ d _ i _ a _ tr _ ic _ s _______________________________ _ 29. Rational Drug Therapy Anu Thukral, Ashok K Deorari 739 30. Integrated Management of Neonatal and Childhood Illness 751 AK Patwari, S Aneja IMNCI strategy 751 Outpatient management of young infants age up to 2 months 752 Outpatient management of sick child age 2 months upto 5 years 758 Revision in IMNCI guidelines 767 31. Rights of Children Rajeev Seth Child abuse and neglect 769 Adoption 770 Index 768 773 Introduction to Pediatrics The branch of medicine that deals with the care of children and adolescents is pediatrics. This term has roots in the Greek word pedo pais (a child) and iatros (healer). Pediatrics covers the age group less than 18 yr of age. A physician who specializes in health care of children and adolescents is a pediatrician. The goal of the specialty is to enable a child to survive, remain healthy, and attain the highest possible potential of growth, development and intellectual achievement. Child health encompasses approaches, interventions and strategies that preserve, protect, promote and restore health of children at individual and population level. Children under 15 yr of age comprise about 30% of India's population. Childhood is the state when the human being is growing and developing. It is time to acquire habits, values and lifestyles that would make children responsible adults and citizens. The family, society and nation are duty bound to make children feel secure, cared for, and protected from exploitation, violence and societal ills. Female children face gender bias in access to healthcare and nutrition. A civilized society nurtures all its children, girls and boys alike, with love, generosity and benevolence. Child is not a miniature adult. The principles of adult medicine cannot be directly adapted to children. Pediatric biology is unique and risk factors of pediatric disease are distinct. Clinical manifestations of childhood diseases may be different from adults. Indeed, many disorders are unique to children. Drug dosages in children are specific and not a mathematical derivation of the adult doses. Nutrition is a critical necessity for children not only to sustain life, but to ensure their growth and development. Pediatrics as a Specialty Pediatrics is a fascinating specialty. It encompasses care of premature neonates on the one hand, and adolescents, on the other. The discipline of pediatrics has branched into well developed superspecialties (such as neonatology, nephrology, pulmonology, infectious disease, critical care, 1 Vinod K Paul neurology, hematooncology, endocrinology and cardiology). Pediatrics covers intensive care of neonates and children using the most sophisticated technology, on the one hand, and providing home care to newborns and children, on the other. Child health is thus a state-of-art clinical science as well as a rich public health discipline. Medical students should possess competencies for the care of healthy and sick children. The agenda of high child mortality due to pneumonia, neonatal infections, preterm birth complications, diarrhea, birth asphyxia and vaccine preventable diseases is still unfinished. The benefits of advancing pediatric specialties must reach all children. Besides, an increasing body of knowledge on pediatric origins of noncommunicable diseases of the adult is set to change the paradigm of child health. Primary prevention, identification of early markers and timely treatment of adult disorders are the emerging imperatives in pediatrics. Historical Perspective Medical care of children finds place in the ancient Indian, Greek and Chinese systems of health. But as a formal discipline, pediatrics took root in Europe and the US in the 19th century when some of the famous children hospitals were established. BJ Hospital for Children, Mumbai was the first child hospital to be established in India in 1928. Postgraduate diploma in pediatrics was started there in 1944; postgraduate degree programs began in the fifties. Pediatrics became an independent subject in MBBS course in mid-nineties. The first DM program in neonatology started in 1989 at PGIMER, Chandigarh and in pediatric neurology at AIIMS in 2004. Challenge of High Child Mortality India has the highest number of child births as well as child deaths for any single nation in the world. Each year, as many as 27 million babies are born in the country. This comprises 20% of the global birth cohort. Of the 7.8 million ___ e_s _s _e _n _t _ i a_l_P_e_d _i a_t _n_·cs---------------------------------- under 5 child deaths in the world in 2010, 1.7 million (23%) occur in our country. The mortality risk is highest in the neonatal period. National programs focus generally on child deaths under the age of 5 yr (under-5 mortality). Table 1.1 provides the most recent figures on the key child mortality indices. Indices Table 1.1: Child mortality indices in India Level in 2012 Under 5 mortality rate (USMR) Infant mortality rate (IMR) Neonatal mortality rate (NMR) Early neonatal mortality rate (ENMR) 52 per 1000 live births 42 per 1000 live births 29 per 1000 live births 23 per 1000 live births USMR Number of deaths under the age of 5 years per 1000 live births !MR Number of deaths under the age of 1 year per 1000 live births NMR Number of deaths under the age of 28 days per 1000 live births ENMR Number of deaths under the age of 7 days per 1000 live births In terms of under 5 mortality (U5MR), India ranks 46th among 193 countries. The U5MR in India (52 per 1000 live births) is unacceptably high given our stature as an economic, scientific and strategic power. U5MR in Japan (3), UK (5), USA (8), Sri Lanka (17), China (18) and Brazil (19) is worth comparing with that of India. Great nations not only have negligible child mortality, but also ensure good health, nutrition, education and opportunities to their children. Majority (56%) of under 5 deaths occur in the neonatal period (<28 days of life), and the neonatal mortality accounts for 70% infant deaths. There has been a steady decline in child deaths. U5MR has declined by almost 50% between 1990 and 2010 from 117 to 59 per 1000 live births. However, decline in neonatal mortality rate (NMR) has been slower. In the decade of 2001-10, infant mortality rate (IMR) declined by 34%, while NMR decreased by 17.5% (Fig. 1.1). More worrying is the fact that the level of early neonatal mortality (deaths under 7 days of life) has remained unchanged. 80 70 60 50 40 30 20 15 10 Reduction in infant mortality is the foremost development goal of the country. India is a signatory of the millennium declaration and thereby committed to the Millennium Development Goals (MDC). The MDC 4 encompasses reduction of U5MR by two-thirds by 2015 from the 1990 baseline. Since the U5MR in 1990 was 117 per 1000 live births, the MDC 4 goal is to attain U5MR of 39 per 1000 live births by 2015. This corresponds to an IMR of 29 per 1000 live births. Given the prevailing levels (Fig. 1.1), India would have to further accelerate her child survival action to attain MDC 4. This is difficult, but achievable. The XII Plan aims to bring IMR to 25 per 1000 live births by 2017. Why do children die? The eight important causes of under 5 mortality in children in India are: (i) pneumonia (24%), (ii) complications of prematurity (18%), (iii) diarrhea (11 %), (iv) birth asphyxia (10%), (v) neonatal sepsis (8%), (vi) congenital anomalies (4%), (vii) measles (3%), and (viii) injuries (3%) (Fig. 1.2). The above causes are the proximate conditions that lead to death. Poverty, illiteracy, low caste, rural habitat, harmful cultural practices, and poor access to safe water and sanitation are important determinants of child health. Undernutrition is a critical underlying intermediate risk factor of child mortality, associated with 35% of under 5 child deaths. Undernutrition causes stunting and wasting, predisposes to infections and is associated with adult disorders (hypertension, diabetes, heart disease) and low economic productivity. Health System in India The rural health system in India is depicted in Fig. 1.3. At the bottom of the pyramid is the village with an average population of 1,000. There are two workers at this level, an Accredited Social Health Activist (ASHA) who is a woman volunteer from the same village placed as the frontline worker of the health sector, and an Anganwadi -+- IMR ..... NMR ...,_ EarlyNMR "*" Late NMR 0 +---r----,---,----,---,---,---,-----r---,----,---,-------,------, 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Fig. 1.1: Trends in neonatal and infant mortality rates (Data from Sample Registration System) Introduction to Pediatrics - Pneumonia 24% Pneumonia 16% Neonatal pneumonia _-._-__ 8% Other disorders 14% Injury 3% 3% Diarrhea 11% Neonatal sepsis 8% Neonatal infections 18% Neonatal diarrhea 2% Prematurity 18% Other neonatal Malformations conditions 3% 4% Fig. 1.2: Causes of under 5 child deaths. The area to the right of the dotted line indicates neonatal conditions Pediatrician, MO, nurses Population Medical colleges Tertiary hospitals Pediatrician, MO, nurses District hospitals (n=615) 1800,000 Pediatrician, MO, nurses Community health centers (n=4,809) 500,000 100,000 MO, nurses Primary health centers (n=23,887) 30,000 ANM Subcenters (n=148,124) 5,000 ASHA Village AWW 1,000 Fig. 1.3: Rural health system in India. ANM auxiliary nurse midwife; ASHA accredited social health activist; AWW anganwadi worker, MO medical officer worker of the health sector, and an Anganwadi Worker (A WW), belonging to the Integrated Child Development Services (ICDS), and responsible for nutrition and child development services. For every 5,000 population, there is a subcenter where 1-2 Auxiliary Nurse Midwives (A.NM) are posted. The roles of ASHA, AWW and A.NM in maternal, newborn and child health are shown in Table 1.2. A primary health center (PHC) caters to a population of 30,000 and is manned by one or two medical officers and nurses. A community health center (CHC) covers a popu lation of 100,000 and has provision for general medical officers as also specialists, including a pediatrician. District hospitals and medical college hospitals provide more advanced specialty services. The private practitioners and facilities are primarily located in urban areas. Rural population also accesses services of unqualified practi tioners which are not a part of the formal health sector. Unlike the rural system, the urban health system is unstructured with multiple providers and dominance of private sector for health care services. National Programs on Child Health Child health has been at the core of our health policy. The Universal Immunization Program launched in 1985 focused on immunization against six diseases (tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles). The Diarrheal Disease Control Program was initiated in 1981 and Acute Respiratory Infections Control Program in __ E _ s _ s _ e _ n _ t _ ia _ l _ P _ e _ d _ i _ a _ tr _ ic _ s _________________________________ _ Provider Table 1.2: Roles of grassroots functionaries in child health Role in maternal, newborn and child health Accredited Social Health Activist (ASHA) Mobilizing pregnant mother for antenatal check and care Accompanying pregnant mother to facility for delivery Home care of the newborn Facilitating immunization Promoting complementary feeding Primary care in diarrhea and pneumonia Health education Anganwadi Worker (AWW) Providing nutrition supplement to pregnant mother Facilitating antenatal checks and immunization Promoting infant and young child feeding Growth monitoring of children Supplementary nutrition to children Managing malnourished children Providing IMNCI services for neonates and children Nonformal preschool education Auxiliary Nurse Midwife (ANM) Antenatal checks and care of pregnant mothers Immunization Supervising ASHA and A WW in newborn and child care Providing IMNCI services for neonates and children Health education IMNCI Integrated Management of Neonatal and Childhood Illness 1990. In 1992, India launched the Child Survival and Safe Motherhood Program (CSSM) by combining interventions for child survival (immunization, control of diarrheal disease, respiratory infections, vitamin A supplementation, essential newborn care) and maternal health (antenatal care, deliveries in institutions, emergency obstetric care). In 1997, the Program for Family Planning and the CSSM Program were merged to create the Reproductive and Child Health Program. In phase 2 of the RCH Program (2005), adolescent health component was added. The government launched the National Rural Health Mission (NRHM) in 2005. This mission included investment in public health, improvements in health systems, focus on communities, decentralization and demand-side interventions to improve effectiveness of the programs. The RCH Program was integrated into the NRHM, with prime focus on child and maternal health. Strategies include deployment of more than 900,000 ASHAs; an increase in ANMs, nurses and doctors; setting up of village health and sanitation; strengthened primary health care infrastructure; strengthened program management capacity, establishment of patient welfare committees at facilities and creation of emergency transport networks. The RMNCH+A Strategy (2073): Ongoing Programs for Neonates, Children and Adolescents In 2013, the government reviewed maternal and child health program under NRHM and launched a Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) under the XII Plan. The intervention packages under the RMNCH+A strategy are summarized in Table 1.3; details are shown in Table 1.4. Table 1.3: Intervention packages under the RMNCH+A Strategy Adolescent health Adolescent nutrition and folic acid supplementation Adolescent Friendly Health Services (Adolescent Health Clinics) Counseling on adolescent reproductive health and other health issues Scheme for promotion of menstrual hygiene among rural adolescent girls Preventive health checkups and screening for diseases, deficiency and disability Pregnancy, child birth and immediate newborn care Preventive use of folic acid in periconceptional period Antenatal package and tracking of high-risk pregnancies Skilled obstetric care and essential newborn care including resuscitation Emergency obstetric and newborn care (EmONC) Postpartum care for mother and baby Postpartum IUCD insertion and sterilization Implementation of preconception and prenatal diagnostic techniques Act Newborn and child care Home based newborn care Facility based newborn care Integrated Management of Common Childhood Illnesses Immunization Child health screening and early intervention (Rashtriya Bal Swasthya Karyakram) Reproductive health Community based doorstep distribution of contraceptives Promotion of spacing methods Sterilization services Comprehensive abortion care Prevention and management of sexually transmitted diseases or reproductive infections IUCD intrauterine contraceptive device Introduction to Pediatrics - Future of Child Health The nation is addressing child health challenges with greater dynamism than ever before. Investments are being made for health programs and health system strengthening. Conditional cash transfers and entitlements are enshrined to stimulate demand for maternal, newborn and child health care. ICDS is being strengthened, particularly in high burden districts to address childhood undernutrition. The country is surging ahead with stronger economy and accelerated development. India is poised to attain low child mortality rate, and improve remarkably the health and nutrition status of her children in near future. Table 1.4: Summary of maternal, newborn and child health services in the RMNCH+A Strategy under NRHM Pregnancy, childbirth and Interventions immediate newborn care Skilled obstetric care and essential Package newborn care including resuscitation Facility deliveries by skilled birth attendants Neonatal resuscitation Emergency obstetric and newborn care (EmONC) Postpartum care for mother and baby Newborn and child care Home-based newborn care Facility-based newborn care Essential newborn care (warmth, hygienic care, breastfeeding, extra care of small babies, problem detection) Linkages to facility-based newborn care for sick neonates Program drivers: The schemes that drive uptake of the intervention packages Janani Suraksha Yojana (]SY) that provides cash incentive to the woman (and to the ASHA) for delivery in the facility Janani Shishu Suraksha Karyakram (JSSK) that entitles the mother and less than one month neonate to free delivery, medicines/blood, diet, pickup and drop in government facilities Navjat Shishu Suraksha Kan;akram that aims to train nurses and doctors in neonatal resuscitation Interventions Home visits by ASHAs (six for facility born babies, on days 3, 7, 14, 21, 28 and 42; an extra visit on day 1 for home births) Interventions for infants Examination; counsel for warmth; breastfeeding; hygiene; extra care of low birthweight babies; detection of sickness, referral Interventions for mother Postpartum care and counseling for family planning ASHA given cash incentive for home care, birthweight record, birth registration and immunization (BCG, first dose OPV and DPT) Special newborn care units (SNCU) These specialized newborn units at district hospitals with specialized equipments including radiant warmers. These units have a minimum of 12-16 beds with a staff of 3 physicians, 10 nurses and 4 support staff to provide round the clock services for new born requiring special care, such as those with very low birthweight, neonatal sepsis/ pneumonia and common complications Newborn stabilization units (NBSU) These are step down units providing facilities for neonates from the periphery where babies can be stabilized through effective care. These are set up in CHCs and provide services, including resuscitation, provision of warmth, initiation of breastfeeding, prevention of infection and cord care, supportive care: oxygen, IV fluids, provision for monitoring of vital signs and referral Newborn care comers (NBCC) These are special corners within the labor room at all facilities (PHC, CHC, DH) where deliveries occur. Services include resuscitation, provision of warmth, prevention of infections and early initiation of breastfeeding Program drivers: The schemes that drive uptake of the intervention packages Janani Shishu Suraksha Kan;akram (JSSK) that entitles the mother and neonate to free delivery, medicines/blood, diet, pickup and drop in government facilities Contd ... ___ E_s_s_e_n_t_ia_t_P_e_d_i_a _tr_ic_s __________________________________ _ Table 1.4: Summary of maternal, newborn and child health services in the RMNCH+A Strategy under NRHM (Contd.) Newborn and child care Integrated management of common childhood illness Immunization Child health screening and early intervention services (Rashtriya Bal Swasthya Karyakram) Interventions Integrated Management of Neonatal and Childhood Illness (IMNCI) by Anganwadi Workers and first level facility (PHC) Facility - IMNCI at first referral level (e.g. CHC). Focuses on providing inpatient management of major causes of childhood mortality such as asphyxia, sepsis, low birth-weight and pneumonia, diarrhea, malaria, meningitis and severe malnutrition Universal Immunization Program now includes 7 vaccine preventable diseases (TB, polio, diphtheria, pertussis, tetanus, measles and hepatitis B) for all children Pentavalent (DPT, hepatitis B and Haemophilus) vaccine introduced in several states MMR vaccine introduced by some states such as Delhi Japanese encephalitis vaccine in endemic districts; combine with routine immunization OPV supplementary doses administered on National Immunization Days to keep India polio free Launched in January 2013, the program envisages child health screening and early intervention services through mobile health teams at block level Screening of all children (0-6 yr old) enrolled at least twice a year for 30 disorders (4Ds) Defects (neural tube defect, Down syndrome, cleft lip/palate, club foot, dysplasia hip, congenital cataract or deafness, congenital heart diseases and retinopathy of prematurity) Deficiencies (anemia, vitamin A deficiency, vitamin D deficiency, severe acute malnutrition and goiter) Diseases (skin conditions, otitis media, rheumatic heart disease, reactive airway disease, dental caries and convulsions) Development delays and disabilities (vision or hearing impairment, neuromotor impairment, motor delay, cognitive delay, language delay, behavior disorder, learning disorders, attention deficit hyperactivity disorder) Optional (congenital hypothyroidism, sickle cell anemia, beta thalassemia) Free management of these children at District Early Interventions Centers or identified tertiary level institutions CHC community health center; DH district hospital; PHC primary health center Suggested Reading Government of India, Ministry of Health and Family Welfare. A strategic approach to Reproductive, Maternal Newborn, Child and Adolescent Health (RMNCH+A) in India January 2013 Liu L, Johnson HL, Cousens S, et al. Global, regional and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 2012;379:2151-61 Normal Growth and its Disorders Ramesh Agarwal, Naveen Sankhyan, Vandana Jain Growth is an essential feature that distinguishes a child from an adult. The process of growth starts from the time of conception and continues until the child grows into a fully mature adult. The terms 'growth' and 'development' are often used together, but are not interchangeable because they represent two different facets of the dynamics of change, i.e. those of quantity and quality. The term growth denotes a net increase in the size or mass of tissues. It is largely attributed to multiplication of cells and increase in the intracellular substance. Hypertrophy or expansion of cell size contributes to a lesser extent to the process of growth. Development specifies maturation of functions. It is related to the maturation and myelination of the nervous system and indicates acquisition of a variety of skills for optimal functioning of the individual. Growth and development usually proceed concurrently. While they are discussed separately, both growth and development are closely related; hence, factors affecting one also tend to have an impact on the other. During early embryonic period of life, an exponential increase in the number of cells occurs. At the early embryonic stage, fetal cells divide and differentiate to form tissues and organs. In the later half of pregnancy and early childhood, there is also an increase in cell size. This manifests as increase in the protein to DNA ratio. The cell size continues to enlarge until about ten years of age. The body cells remain in a state of dynamic equilibrium; hence aging cells are continuously replaced by new cells. The rate of turnover of cells in different tissues is variable. FACTORS AFFECTING GROWTH Fetal Growth Fetal growth is influenced primarily by fetal, placental and maternal factors. In humans, 40% of variation in the birth weight is due to genetic factors while the rest is due to environmental factors. The fetus has an inherent growth 7 potential, and under normal circumstances, grows into a healthy appropriate sized newborn. The maternal placental-fetal unit acts in harmony to provide the needs of the fetus. Genetic potential. Parental traits are usually transmitted to the offspring. Thus, tall parents have tall children; the size of the head is more closely related to that of parents than are the size and shape of hands and feet. Similarly, the structure of the chest and fatty tissue has better genetic association than other somatic characteristics. Sex. Boys are generally taller and heavier than girls at the time of birth. Fetal hormones. Human fetus secretes thyroxine from the 12th week of gestation. Thyroxine and insulin have an important role in regulating tissue accretion and differentiation in the fetus. Both hormones are required for normal growth and development, particularly during late gestation. Gluco corticoids also play an important role, primarily towards the end of gestation and influence the prepartum maturation of organs such as liver, lungs and gastrointestinal tract. Growth hormone, though present in high levels in fetus, is not known to influence fetal growth. Fetal growth factors. A large number of growth factors are synthesized locally in fetal tissues, and act principally by autocrine and paracrine mechanisms. Their prime effect is on cell division, though they also influence other aspects of tissue growth. These factors can be both growth promoting or inhibitory. The insulin like growth factor (IGF)-1 and IGF-11 are among the most extensively studied fetal growth factors. Other growth promoting factors include epidermal growth factor (EGF), transforming growth factor (TGF-a), platelet derived growth factor (PDGF), fibroblast growth factor (FGF) and nerve growth factor. Inhibitory factors include TGF-�, Mullerian inhibitory substance and inhibin/ activin family of proteins. __ E_s_s_e_n_ t_ia_i_P_e_d_i_a _t r.i.cs---------------------------------- Placental factors. As in most species, fetal weight directly correlates with placental weight at term. Fetal growth is highly dependent on the structural and functional integrity of the placenta. With advancing gestation, the weight of the placenta increases to cater to the increased needs of the baby. There are important functional and structural changes in the placenta that make this adaptation more efficient. The total villous surface area increases, the diffusion distance decreases, the fetal capillaries dilate and the resistance in fetoplacental vasculature falls. This positive remodeling facilitates nutrient transport across the placenta. Maternal factors. The mother's own fetal and childhood growth and her nutrient intake and body composition at the time of conception and during pregnancy, play an important role in determining fetal size. Teenage or advanced age, recent pregnancy, high parity and anemia negatively influence fetal size and health. Maternal intake of tobacco (smoked or chewed) and drug or alcohol abuse also retard fetal growth. Obstetric complications such as pregnancy induced hypertension, pre-eclampsia and multiple pregnancies produce fetal growth restriction. Pre existing chronic systemic disease (chronic renal failure, congestive heart failure) and acquired infections (rubella, syphilis, hepatitis B, HIV, CMV, toxoplasmosis) may influence fetal growth. Postnatal Period The growth of the child during postnatal life is determined by genetic potential as well as internal and external influences. Genetic factors. Both chromosomal disorders and mutations in specific genes can affect growth. Chromosomal defects like Turner syndrome and Down syndrome manifest as growth retardation. Mutation of single genes may result in inherited retardation of growth, e.g. Prader-Willi syndrome and Noonan syndrome. While most disorders lead to short stature, some genetic defects can also result in tall stature, e.g. Klinefelter syndrome and Sotos syndrome. 70 -60 � £ 50 E "'40 � 30 "' C: {I> 20 :g :.c u 10 _._ Stunted --- Underweight --- Wasted Intrauterine growth restriction (IUGR). IUGR resulting in low birthweight (LBW) constitutes an important risk factor for postnatal malnutrition and poor growth. LBW increases the odds of underweight, stunting and wasting in the first 5 yr of life by 3 to 5 times. At 6 months of age, approximately one-third each of underweight (28%), stunting (28%) and wasting (22%) are attributable to LBW. At ages between 1 and 5 yr, LBW accounts for 16-21 % of wasting, 8-16% of stunting and 16-19% of underweight. It was recently reported that a third and a fifth of infants have wasting and stunting, respectively, even at birth (Fig. 2.1). During early infancy, exclusive breastfeeding provides adequate nutrition, prevents infections and protects the infants from further undernourishment. However, at 3-5 months, the common practice of supplementing the infants with animal milk increases morbidity due to infections leading to underweight and stunting. Subsequently, faulty complementary feeding practices (starting too late, using too little and very less calorie dense foods) along with poor hygiene lead to a further rise in rates of underweight and stunting. Hormonal influence. Normal development cannot proceed without the right milieu of hormones in the body throughout childhood and adolescence. Absence of growth hormone or thyroxine results in dwarfism, underscoring the importance of these factors in promoting growth. These hormones influence both somatic and skeletal growth. During adolescence, androgens and estrogens have an important influence on the growth spurt and final adult height. Sex. The pubertal growth spurt occurs earlier in girls. However, their mean height and weight in girls are usually less than those in boys of corresponding ages at the time of full maturity. Nutrition. Growth of children suffering from protein-energy malnutrition, anemia and vitamin deficiency states is retarded. Calcium, iron, zinc, iodine and vitamins A and D are closely related to disorders of growth and development 0+---r-.---��-��-�---,-�-.----,----,--,---r-.---,---r-.---��-��-��-�� 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Age (months) Fig. 2.1: Proportion of children with stunting, underweight and wasting among children from birth to 5 yr. Reproduced with permission from Paul, et al. Lancet 2011;377,332-49 and their deficiency is associated with adverse health events in childhood (see Chapter 7). On the other hand, overeating and obesity accelerate somatic growth. Infections. In low resource settings, one of the commonest contributors to poor childhood growth are infections. Persistent or recurrent diarrhea and respiratory tract infections are common causes of growth impairment. Systemic infections and parasitic infestations may also retard the velocity of growth. The risk of stunting at 2 yr of age is shown to increase with each episode of diarrhea and with each day of diarrhea before 2 yr of age. It was also shown that the attributable risk for stunting for 5 or more episodes of diarrhea before 24 months of age was 25%. Chemical agents. Administration of androgenic hormones initially accelerates the skeletal growth. However, androgens cause the epiphyses of bones to close prematurely, leading to early cessation of bone growth. Trauma. A fracture at the end of a bone may damage the growing epiphysis, and thus hamper skeletal growth. Social Factors Socioeconomic level. Children from families with high socioeconomic level usually have better nutritional state. They suffer from fewer infections because of better nutrition and hygienic living conditions. Poverty. Hunger, undernutrition and infections, often associated with poverty, cause poor growth. Natural resources. Plentiful natural resources encourage industrial and agricultural enterprise in the country. Improved nutrition of children in the community is facilitated when there is a climb in gross national product and per capita income is high. Climate. The velocity of growth may alter in different seasons and is usually higher in spring and low in summer months. Infections and infestations are common in hot and humid climate. Weather also has a pivotal effect on agricultural productivity, ready availability of food and capacity for strenuous labor by the population. Emotional factors. Children from broken homes and orphanages do not grow and develop at an optimal rate. Anxiety, insecurity and lack of emotional support and love from the family prejudice the neurochemical regulation of growth hormone release. Parents who had happy childhood and carry a cheerful personality are more likely to have children with similar countenance. Cultural factors. Methods of child rearing and infant feeding in the community are determined by cultural habits and conventions. There may be religious taboos against consumption of particular types of food. These affect the nutritional state and growth performance of children. Parental education. Mothers with more education are more likely to adopt appropriate health promoting behaviors, Normal Growth and its Disorders - which have direct and indirect influences on growth and development. Consequences of Impaired Growth Maternal and child undernutrition are the underlying cause of 3-5 million deaths annually and account for 35% of the disease burden in children younger than 5 yr. It is estimated that India has more than 61 million stunted children, that amounts to 34% of the global total. Several major disorders of later life, including coronary heart disease, hypertension and type 2 diabetes, originate from impaired intrauterine growth and development. These diseases may be consequences of 'programming', whereby a stimulus or insult at a critical, sensitive period of early life has permanent effects on structure, physiology and metabolism. The 'fetal origins' hypothesis (Barker hypothesis) proposes that alterations in fetal nutrition and endocrine status result in developmental adaptations that permanently change structure, physiology and metabolism, thereby predisposing individuals to cardiovascular, metabolic and endocrine disease in adult life. As a result, infants born with low birthweight have increased risk of diabetes, hypertension, coronary artery disease and hyperlipidemia in adult life. Laws of Growth Growth and development of children is a continuous and orderly process There are specific periods in a child's life when the rate of growth is steady, accelerates or decelerates (Table 2.1). The fetus grows fast in the first half of gestation. Thereafter, the rate of growth is slowed down until the baby is born. In the early postnatal period the velocity of growth is high, especially in the first few months. Thereafter, there is slower but steady rate of growth during mid-childhood. A second phase of accelerated growth occurs at puberty. Growth decelerates thereafter for some time and then ceases altogether. The general body growth Table 2.1: Periods of growth Prenatal period Ovum Embryo Fetus Perinatal period Postnatal period Newborn Infancy Toddler Preschool child School age child Adolescence Early Middle Late 0 to 14 days of gestation 14 days to 9 wks 9 wks to birth 22 wks to 7 days after birth First 4 wks after birth First year 1-3 yr 3-6 yr 6 -12 yr 10-13 yr 14-16 yr 17-20 yr __ E _ s _ s _ e _ n _ t _ i a _ r _ P _ e _ d _ ia _ t _ ri _ c _ s _______________________________ _ 23 22 21 20 19 18 17 16 10 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Centiles for girls ---------- 97 maturin�at ------ 90 average time 7 5 97 and 3 centiles at peak height velocity for: ...............•...••.... 50 --·- 25 - - - - - - - 10 •••••••••••••••• 3 I\ V Early (+2SD) maturers - - - - - - - - - Late (-2SD) maturers _ _ _ _ _ _ _ � _ 97 , I\ 00\� I \ 75 '\ '\ ', I�\ A 9 Early ·, '- ,. '/ \' 50 ,.,. '', ... 11\ \ 3 Late'}.�'·,. ·, ',, / \� 'l"\ \\\ 25 ..... ,,. '- -- I '\/• ·'\, ....... �·, .... '-.::..-7--" ;�·/ "\\\1,1•• 10, ... ;<� .. �:::-·-· ;;---Q// '"'\ {\\V\ I '-. '°'.;.'" ...... -�--_....I V '.t�\, I 3 ·-. '' -....:: • .i._-:.·-:.··············'/ /,\··-.,.\\\' \ ·. - ...... _ ,. ,'\i'�. ·-·-... -: - - - -�"<. _,: ... " \'\\\}, ' ·· .............. · \\\��\ \ ,-._,�\�, ·. '··.' \\ '�, '. \"-"�i') \ ,�, \ : ' 23 22 21 20 19 18 17 16 10 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Gentiles for boys ---------- 97 maturing at ------ 90 average time ------ 75 97 and 3 cenliles at peak height velocity for: ·························50 25 - - - - - - ·10 •.•••••••••••••• 3 I\ V Early (•2SD) malurers - - - - - - - - - Late (-2SD) maturers ___ •• __ _ I\ A 2 3 4 5 6 1 8 9 1o 11 12 13 14 15 16 17 18 19 B 1 2 3 4 5 6 1 8 9 10 11 12 13 14 15 16 11 18 19 Age, years Age, years Fig. 2.2: Normal height velocity (A) girls and (B) boys according to age. Curves for height velocity at 50th centile for early and late maturers are also depicted The open arrow heads indicate the third and 97th centile for peak height velocity for these individuals. Reprinted from J Pediatr 1985;107317-29; with permission from Elsevier is rapid during the fetal life, first one or two years of postnatal life and also during puberty (Fig. 2.2). In the intervening years of mid childhood, the somatic growth velocity is relatively slowed down. Growth pattern of every individual is unique Order of growth is cephalocaudal and distal to proximal. During fetal life, growth of head occurs before that of neck, and arms grow before legs. Distal parts of the body such as hands increase in size before upper arms. In the postnatal life, growth of head slows down but limbs continue to grow rapidly. Different tissues grow at different rates (Fig. 2.3) Brain growth. The brain enlarges rapidly during the latter monthsoffetallifeandearlymonthsofpostnatallife.Atbirth, the head size is about 65-70% of the expected head size in adults. It reaches 90% of the adult head size by the age of2 yr. Thus, the fetal phase and the first two years are crucial periods for brain development. Later periods are also impor tant for acquiring neuromotor functions and cognitive ability. Growth of gonads. Gonadal growth is dormant during childhood and becomes conspicuous during pubescence. Lymphoid growth. The growth of lymphoid tissue is most notable during mid-childhood. During this period, the 2 2 Brain growth 8 Age in years 8 Age in years 12 2 12 2 100% 8 12 Age in years Gonadal growth 8 12 Age in years Fig. 2.3: Rates of growth of different tissues and organs lymphoid tissue is overgrown and its mass may appear to be larger than that of the fully mature adult. A sign of