CHAPTER IV SOCIAL AND PREVENTIVE PEDIATRICSPediatrics is that branch of medicine that deals with the care of children from conception of adolescence, in health and disease. Pediatrics is one of the first clinical subjects to links itself to preventive medicine. Like obstetrics, pediatrician has a large component of preventive and social medicine. There is no other discipline so comprehensive as pediatrics that teaches the values of preventive medicine. Recent you have witnessed further speculatin within the broad build of pediatrics like preventive pediatrician, neonatology, perinatology, development pediatrician, pediatric surgery, pediatric neurology etc. The aim of preventive pediatrics is the prevention of disease and promotion of physical, mental and social well being of children so that each child may achieve the genetic potential with which he/she is born. Primary health care with the potential for vastly increased coverage through an integrated system of service delivery is increasingly looked upon as the best solution to reach millions of children especially those who are most in need of preventive and corrective services.

Social pediatrics has been defined as the application of the principles of social medicine to pediatrics to obtain a more complete understanding of the problem of children in order to prevent and treat disease and promote their adequate growth and development, through an organized health structure. Social pediatrics is concerned with the delivery of comprehensive and continuous child health care services and to bring these services within the reach of the community. It covers the various social welfare measures, local, national and international aimed to meet the total health needs of a child.THE CARE OF CHILDREN

More focus is given in all societies regarding the health of children, not because they constitute about 40% of the total population but because there is renewed awareness that the determents of chronic disease in later life and health behavior are laid down in this stage. The childhood period is a vital period because of the socialization process and their vulnerability to disease, death and durability. Certain specific and healthy development of child and future adult. Childhood is divided into the following age periods1. Infancy (up to 1 year of age)

(a) Neonatal period (birth to 28 days)

(b) Post neonatal period (28 days to 1 year)2. Pre-school age (1 4 years)

3. School age (5 11 years)

Antenatal Pediatrics

Fifty years ago the main purpose of ANC was prevention of maternal mortality with fall of maternal mortality to 0.2 per 1000 live birth, attention shifted to child first to decrease peri-natal mortality secondary to prevent prenatal morbidity and recently to the fetus at risk. Antenatal care begin even before the mother conceives and enters the maternity cycle, this care composes genetic counseling for prospective parents, spacing births, delaying first pregnancy till physically and socially mature and adequate maternal nutrition. Improved maternal nutrition, protection of unborn against infection, family planning and usually goes a long way in ensuring maternal and fetal health.

Care of Infants 6756/BWB2/05/FIN14/1/05

DME

Infants (0-1 year), consists of 2.92% of total population in India. Although survival of newborn has improved by 50% in last 20 years, the immediate period is still an obstacle race to win 50% of infant mortality occurs in 1st month of life. Half dies during the first week of life and greatest risk is during the first 24 48 hours of birth.Neonatal Screening

The object of screening newborn is to primarily detect infants with treatable genetic, developmental and other abnormalities and secondarily to provide parents with genetic counseling. APGAR score, routine channel examination and cord blood is tested for congenital metabolism disorders, hemoglobilo pathers, red cell disorders and genetic disorders. Eg. PKG, Hypothyrodism, Wombs test, suck cell agale gel electrophoresis.

At risk Infants

`At risk infants are those who require special intensive care due to per chances of perinatal, neonatal and infant motality. The basic criteria for identifying at risk babies ae1. Birth weight less than 2.5 kg

2. Twins

3. Birth order 5 and more

4. Artificial feeding

5. Weight below 70% conjugated weight

6. Failure to gain weight for 3 successive months

7. PEM, Diahorrea

8. Working mother/parent

Low Birth Infants

The birth weight of an infant is the single most important determinant of its chance of survival, healthy growth and development. There are two main groups of low birth weight babies - those born prematurely (short gestation) and those with fetal growth retardation. A target birth weight of atleast 2.5 kg for 90% of newborn infants and adequate growth of children according to the height-weight ratio together constitute global indicator for monitoring and evaluation of global strategy for health for ALL 2000 AD. Classification

According to gestation age

Preterm Babies born before the end of 37 weeks gestation (259 days)

Term Babies born 37 completed weeks to less than 42 weeks (259 293 days)

Post term Babies born at 42 completed weeks or any time (294 or more) after gestationAn LBW infant with birth weight of less than 2.5 kg regardless of gestational age. In includes 2 kinds of infants.

Preterm babiesBabies born too early before 37 weeks of gestation. Their weight, length and development may be within normal limits for the duration of gestation. If given good neonatal care, babies can catch up growth and in 2-3 years will be of normal size and performance. e. g. Multiple birth, had physical work, PIH, adolescent pregnancy etc.

Small for Date (SFD)

Born term of pre term than the 10th percentile for gestational age. These babies are the result of retarded intrauterine fetal growth. Maternal factors for SFD are malnutrition, anaemia, hypertension, malaria, toxaemia, smoking, low economic status, short maternal stature, very young age, high parity, close birth spacing, low education status etc. Placental causes include placental abnormalities. Fetal causes include fetal abnormalities, intra uterine infections, chromosome abnormality and multiple gestation.Percentage of LBW babies =

25 million low birth weight babies are born all over the world. In India 26% of live birth in India are LBW infants.

Incidence of LBW can be reduced of pregnant women at risk are identified and steps are taken to reduce the risk. Direct intervention to reduce at risk pregnant women are increasing food intake which involves supplementary feeding, distribution of iron and folic acid tablets and fortification and enrichment of foods.

Under 5s clinic

Although well baby clinic have been functioning for a number of years, it was restarted to Preventive pediatrics, the under five chain combines the concept of prevention, treatment, health supervision, nutritional surveillance and education. The aim and objectives of the under 5s clinic are1. Care in illness: This is the mothers first need. 70-90% of care of sick children can be handled by trained mothers. Basic philosophy of under 5 clinics is to give nurses effective training and responsibility for handling the child health care service. Care includes diagnosis and treatment of acute illness, chronic illness growth and development disorders, X-ray and laboratory services and referred services.

2. Preventive care: Immunization is the worlds greatest public health tool. Nutritional surveillance and supplementary feeding has been taken up by the IDS program. Health develops every 6 months have been recorded on Child Health card to identify high risk children. Oral rehydration is necessary for children with ADD, ORT has opened the way for a drastic reduction in child deaths and malnutrition. Family planning is put in the centre of concern for the health and well being of the child. Health education to the mother is a help to her in rearing her children.3. Growth monitoring: Child is weighed at monthly intervals during the 1st year, every 2 month during the second year and every 3 months thereafter up to the age of 5-6 years.1-4 year Mortality rate (Child Death rate)

It is a refined indicator of the sound situation in the country than IMR. It reflects adverse amount health hazards, including economic, educational and cultural characteristics of a family. Leading causes of death are diarrhoeal disease, respiratory infections, communicable disease like pertusis and measles. Home accidents like falls from stairs and balconies, suffocation, burns and poisoning.

Under 5 mortality rate (Child mortality rate)

UNICEF condemn the rate as the single best indicator of social development and well being than GNP

Child mortality rate =

Global average in 2002 was 82/1000 live birth while in India it was 93/1000 live births

Child survival IndexChild Survival rate =

In India it is 90.7 while in USA it is 99.2. This is a grim pointer to the third world countries need for preventive service

Other direct intervention vehicle controlling infection end. Early detection and treatment of medical disorders. LBW babies under 2 kg should be managed in a modern neonatal care unit while those between 2 and 2.5 kg should need intensive care, alternative feeding and prevention of infection. The leading cause of death in LBW babies are malformation, pulmonary haemorrhage, microcarnial blood, phenomena and other inflation.

Feeding of Infants

Breast Feeding: Breast milk is the ideal food for the infants till 4-5mm after birth. Under normal condition breast milk is recorded 450-600ml daily with 1.1 gm protein/100ml. The energy value of human milk is 70k cells/100 ml. Among the numerable advantages of breast milk the main advantages are

1. Clean safe, hygiene, cheap and available to the infant at correct temperature.

2. Fully meets nutritional requirements of the infant in first few months of life

3. It contains antimicrobial factors like macrophagen, lymphocytes, secretory IgA, antistreptococcal factor, lysozyme and lacto serum which provide protection against ADD and NEC.4. Easily digested by premature babies

5. Promotes maternal-infant bonding

6. Sucking helps in development of jaws and teeth

7. Promotes the baby from obesity tendency

8. Prevents malnutrition and reduce mortality

9. Prevents hypoceaeme and hpomagneseemia

10. Helps space children by prolonging infertility

Artificial Feeding

Main indications of artificial feeding are failure of breast milk prolonged illness or death of mother. In planning breast milk substitutes the option are

1. Dried milk

2. Cows milk

3. Commercial formulae

Principles of Artificial Feeding1. Infants require 150 kcal of energy/kg of body weight/day i.e. 150 ml. milk/kg body weight/day2. Infants require 2g/kg body weight for 1st 6 months and 1.5g/kg body weight till one year i.e. 13 14 gm/day for 1st year of life

3. Infants require 10g/kg body weight of carbohydrate

4. Undiluted boiled, cooled milk can be given after 4 months of age

5. Feeding intervals of 6-8 times/day for infants, 5 times a day for older infants.

6. Calorie needs increased during children should be met

Difference between cows and human milk

(a) Protein: Low protein content in human milk. Amino acids cysteine (essential for premature infants) and taurine (infants cannot synthesize is rich in human milk whle methrome is more in cows milk. Cows milk protein unlike human mil is not fully digested providing whitish, curdy stool. Anti-infective problem like igly, lysozyme and lurvy cells are present in human milk.

(b) Fats: Human milk is rick in fats which represent 35 50% of total energy value. Essential polyunsaturated fatty acids like linoleic acid and -linoleic acid are higher in human milk. In cows milk unabsorbed fatty acids fend to bird with calcium and prevent it from being absorbed. Fats in human milk is easy to absorb.(c) Carbohydrates: More lactose present in human milk before lactobacillus in the intestine to multiply keeping the intestinal contents acidic, intubutory growth of harmful bacteria.

(d) Vitamin, Minerals: Vitamin A, D, C is seen in water to from cows milk. The buo availability of iron is higher than other breast milk substitutes. Human milk is also vector in copper, sclenium and cobalt, than cows milk. As there is less sodium than cows milk, there is no strain on infants kidneys. As Ca/Ph ratio is high, uptake of Ca is better than cows milk.

This shows that human milk is with virtual living fluid.

Weaning

A knowledge of weaning foods and practices is an important aspect of social and preventive pectiarum. It is a geraded process starting around 4-5 months or breast milk is to be supplemented to sustain proper growth and development. Supplementary foods include cows milk, fruit juice, soft cooked rice, dhal and vegetables. By the age of 1 year, solid food consumed yb the family should be given to the child.Growth and Development

Growth refers to increase in the physical size of the body and development to increase in skills and function. These are considered together as child develops as a whole

Factors influency growth and development are

1. Genetic inheritance: Height, weight, mental and social development and personality are influenced by genetic factors.

2. Nutrition: Nutrition influences growth and development before and after birth.

3. Age: Growth rate is maximum during fetal life, 1st year of life and puberty. At other periods growth is slower.

4. Sex: Female Children has a growth spurt at 10-11 years of age while in male children it is between 12 and 13.

5. Physical surrounding: Sunshine, good housing, lightly and ventilators have their effects on growth and development.

6. Psychological factors: love, tender care and proper child-parent relationship effects social, emotional and intellectual development.

7. Infection and infestation: repeated infection and intestinal parasites hamper growth and development.

8. Economic factors: A high standard of living is associated with better height and weight.

9. Other factors: birth order, birth spacing, birth weight, parental education are factors that influence growth and development.

Growth assessment:A normal child is one whose characteristics fall within the range of measurements accepted as normal for the majority of children in the same age group (Assumed to include 2 times standard deviation above and below the 3rd and 97th ) perinnelles. Height, weight, head and chest circumferences are measured.

1. Based on the mean values. A variation of 2 standard deviation from either side of the mean considered normal

2. Based on the percentile: A percentage of under which fuly within the 3rd and 97th ventiles are considered under as over weight.

3. Based on indices like weight/height and age independent indices.

For national and international comparison and for monitoring reference or standard values of growth are essential well known reference standards are1. Harward/Boston standards

2. WHO standards (Based on NCHS statutes UQ National Centre for Health Statutes)

3. Indian Standards (Based on KVR studies from 1956 1965)

Surveillance Growth and Development

An important component of the routine anticipatory care of children, the main purpose of surveillance is to identify those children who are not growing normally.

1. Weight for age: Careful repeated measurements at intervals ideally monthly till 1 year, every 3 month till 5 years. A growth client can change in the rate of growth and halt in gain. An Indian infant manage to grow up well till 3 -4 months at the enquire of its melonatal mother but growth will falter due to lack of supplementary feeding.

2. Height for age: Accurate measuring to an accuracy of 0.1cm is essential to measure children whereas weight reflection present health status, height mediates events in the past also .During smooth spurt boys add 20 cm and girls add 16 cm. Indian girls reach 98% of final height by 16.5 years and boys reach the same stage by 17.75 years.3. Weight for height: Because of its internal relatedness, height in plotted will weight. For eg. Held on the 75th centriole of both height and weight are normal but one who is on the 75th centriole on the weight heart but 25th centriole on his height chart is dearly over weight.

Head and Chest circumference

At birth head circumference is 2 mm more than chest circumference. By 6-9 months, the two measurement are however equal after which the chest circumference over takes the head circumference. In malnourished children over taking is delayed by 3 to 4 years due to poor development of the thoracic cage.

BEHAVIORAL DEVELOPMENT

Behavioral development is assured in the fields of motor, personnel, social, adaptive and language development. Development milestones provides stimulates when the child can be expected to allowing central skulls or points in development. When child does not attain the milestones, possibility of mental handicap should be overlooked.

Growth or road to Health chart

The growth chart was first designed by David Morley and modified by WITO. Any derivation from move can be detected easily by comparison with reference curves. Growth charts offer a simple yet inexperience way of monitory child health with reference to height and weight. If child is growing normally, the growth time will lie between the 3rd and 97th percentile. The direction of growth and the direction of the growth curve is more important and should lie parallel to the road to health curves. Flattening and bathing of of childs weight curve signals growth failure and protein energy malnutrition.

Growth charts used in India

Growth chart recommended by the Govt. of India, formulated by the Indian Academy of Pediatrician has 4 reference curves showing the three degree of malnutrition. If childs weight is between 70-80% lines it shows mild malnutrition, if between 60-70%, it indicates moderate malnutrition and if below 60% it third degree or severe malnutrition. A growth chart has many potential uses1. For growth monitoring

2. For planning and policy making

3. As an educated tool

4. As a diagnostic tool

5. As a tool for action

6. For evaluation

7. As a tool for teaching

Infant Mortality

Infant mortality is regarded as the most important indicator of the health status of a community but 1 due the level of living in people in general. The infant mortality rate is the ratio of infant deaths regulated in a given year to the total number of live births registered in the same year usually expressed as a rate per 1000 live births. India has a high mortality rate 67 in the year 2002 compared to that of 5-8 per 1000 live births. In Kerala it is 14.

Factors affecting Infant mortality

(a) Biological factors

(i) Birth weight

(ii) Age of mother

(iii) Birth order

(iv) Birth spanning

(v) Multiple birth

(vi) Family size

(vii) High fertility(b) Economic factorsThe availability and quality of health care and nature of the childs environment is closely related to socio-economic status. Statistics reveal IMR highest in slums and lowest in richer residential areas.(c) Cultural and Social factors

(a) Breath feeding: The nutritional content and natural immunity contained in breast milk allows fully breast fed infants to have a low IMR.

(b) Religion and caste: Socio-cultural factors of living involving habits, colour, tradition affecting cleanliness, eating, clothing, child care and does not every defail of daily living

(c) Gender of child: Low attention to female infants account for higher female infant mortality rates.

(d) Early marriages: Baby of teen mother has highest risk of neonatal and post neonatal mortality

(e) Quality of mothering: Poor maternal efficiency can cause infant mortality

(f) Maternal education: There is extreme evidence that maternal education play a major role in the decline of infant and child mortality, reflectivity personnel health hilarious, care and access to health services.

(g) Quality of health care: Inadequate prenatal care and infrequent attendance at delivery can lead to high IMR.

(h) Broken families: IMR is high when mother/father have died or separated.

(i) Illegitimacy: Child born out of wed lock is generally unwanted both by the mother as well as society.

(j) Brutal habits and customs: Age old custom and beliefs including depriving infant of colustrium, frequent purging, skin branding, applying cow dung to umbilical cord and early weaning.

(k) Indegenous dai: Untravel mid wives is responsible for high IMR

(l) Bad emf sanitation: Lack of safe water supply, poor housing condition, bad drainage, over crowding, unveit brady all influence IMR.

Preventive, social measures to reduce IMR

Under ideal condition of social welfare, no baby should die except those who die of congenital abnormalities or disorders originating in uterine life.1. Prenatal nutrition: Mounting evidence show that even addition of extra supplementation to the mothers basic diet goes a long way in improving the birth weight of babies. A slowly involved supplementation of 500 kcal of energy and 10g of protein to the last 4 weeks of pregnancy, and the infants birth weights were an average 300g above those infants born to the control group.

2. Prevention of Inflation: Universal immunization programme launched in 1985 even at providing protection to conjectant mothes and children against 6 vaccine preventable decreases.

3. Breast feeding promotion: Safeguard against GIT, respiratory infection PEM.

4. Growth monitoring: Low cost technology to reduce IMR by identify children with malnutrition and giving the spinal health care

5. Family planning: Birth spacing and lesser children have improved infant and child survival

6. Sanitation: Lack of elementary hygiene can contribute to IMR which can be reverted as the society is mobilized to better the simulation.

7. Provision of primary health care: All those involved in maternity care from the obstetrician to the local dai should work to improve prenatal care, to set up special care baby units for babies with 2000 gm and improve referral services.

8. Socioeconomic development: All round health and social development lowers IMR and PMR.

9. Education: Eduation as a driving fork for better health has been extensively studied and documented. IMR has reduced dramatically form 90/1000 cc birth to 57 per live births in 1991 and Tamil Nadu is on the threshold of achieving zero population growth.

Care of the preschool age childrenChildren between 1-4 years of age are generally called pre school age children or toddlers. Now, the preschool age has become a focus for organized medical-social welfare activities and then statistics is considered a significant indicator of the social situation in a country.

Characterisation of Preschool children1. Large numbers: 12% of the general population, a large majority of these children live in rural, tribal children and urban slums. Children are the human resources of the future.

2. Mortality: Preschool children mortality is as high as 11.2% of all deaths mainly due to infection and malnutrition.

3. Morbidity: PEM, other malnutrition deficiency, diahorrea, diphtheria, tetanus, whooping cough, measles, eruptive fevers, skin and eye infections and intestinal parasitic infestations commonly occur. Accidents contribute to pediatric emergencies. Some may manifest during preschool year like heart disease and mental retardation.

4. Growth and development: Any adverse influences affecting the children may result in limitation in their development, which may be irreversible.

5. Accessibility: Children can be accessed through day cares and play groups only and may not enter into the orbit of health care

6. Prevention of health problem in adult life: Longitudinal studies have revealed that the foundation of obesity, hypetension, cardiovascular disease and mental disorders are laid in early life.

Child Health Problem

1. Malnutrition: Scarcity of suitable foods, lack of purchasing power of the families and traditional beliefs and taboos lead to insufficient, balanced diet, leading to malnutrition.(a) Protein energy malnutrition: 43% of children in the developing world (230 million) have low height for age i.e. shunting and 9% (50 million) have low weight for height.

(b) Micronutrient and malnutrition: Nutritional anaemia, vitamin A deficiency and nutritional blindness and iodine deficiency may lead to severe illness, influence physical development, psychic behavior and susceptibility to infection. 2. Infection and parasitic diseases: Young children are easy prey to infectious diseases. There are 4 million death a year from respiratory infection. Prevention and treatment of childrens illnesses can interrupt the transmissions of infection in the community.3. Accidents and poisoning: Accidents in children equally burns and trauma as a result of home accidents and traffic accidents and children and adolescents are particularly vulnerable to domestic accidents including falls, burns, poisoning and drowning.4. Behavioral problems: are increasingly recognized is most problem. The international union for child welfare estimates that there are 1.5 million children with severe social and health problems.5. Maternal health: lifestyle of the family, environmental factors and community and social support measures play a role in determining the health of children._1389847925.unknown

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