Ghai Essential Pediatrics8th

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 70

Kamran Afzal

Composition of body fluids 70 Deficit therapy 72

Sodium 73

Potassium 76

Calcium 79 Magnesium 82 Acid-base disorders 83

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

Common bacterial infections 240

Tuberculosis 250

Fungal infections 259

Protozoa! infections 260

Congenital and perinatal infections 272

Helminthic infestations 273

11.Diseases of Gastrointestinal System and Liver

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

Rheumatic fever and rheumatic heart disease 433

278Infective endocarditis 443 Myocardial diseases 447 Pericardia! diseases 450 Systemic hypertension 451

Pulmonary arterial hypertension 456 Rhythm disorders 457

Preventing adult cardiovascular disease 462

Arvind Bagga, Aditi Sinha, RN Srivastava

Renal anatomy and physiology 464

330Diagnostic evaluation 467 Acute glomerulonephritis 474 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

PSN Menon, Anurag Bajpai, Kanika Ghai

Disorders of pituitary gland 511

Disorders of thyroid gland 516

Disorders of calcium metabolism 521

371Disorders of adrenal glands 523 Obesity 528

Disorders of the gonadal hormones 53l Diabetes mellitus 54l

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

Disorders of skin appendages 682

Papulosquamous disorders 684

599Disorders of pigmentation 686 Drug eruptions 686

Infections 687

Diseases caused by arthropods 694

22. Genetic Disorders

Neerja Gupta, Madhulika Kabra

Chromosomal disorders 636 Single gene disorders 64l 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

Sidharth Kumar Sethi. Arvind Bagga

30. Integrated Management of Neonatal

AK Patwari, S Aneja

IMNCI strategy 751

Outpatient management of young infants age up to 2 months 752

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 theother. The discipline of pediatrics has branched into well­ developed superspecialties (such as neonatology, nephrology, pulmonology, infectious disease, critical care,

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 earlymarkers andtimely 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

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 1.1providesthe most recentfigureson the key child mortality indices.

Table 1.1: Child mortality indices in India

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.

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 MDC4 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?

Theeightimportantcauses of under 5mortality inchildren 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 andsanitation are importantdeterminants ofchild 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

worker of the health sector, and an Anganwadi Worker (AWW), belonging to the Integrated Child Development Services (ICDS), and responsible for nutrition and child development services. For every5,000population, there is asubcenter where 1-2 AuxiliaryNurse Midwives (A.NM) areposted.Therolesof ASHA,AWWand A.NM inmaternal, newborn and child health are shown in Table 1.2.

A primaryhealthcenter (PHC) caters to a population of 30,000 and is manned by one or two medical officers and nurses. A communityhealth center (CHC) covers a popu­ lation of 100,000 and has provision for general medical officersas alsospecialists,includinga pediatrician.District hospitals and medical college hospitals provide more advancedspecialty 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 sectorfor healthcareservices.

National Programs on Child Health

Child health has been at the core of our health policy. The Universal Immunization Program launched in 1985 focusedonimmunizationagainstsixdiseases (tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus andmeasles). The Diarrheal Disease Control Program was initiated in 1981 and AcuteRespiratoryInfections Control Programin

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 Programwere merged to createthe 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 900,000ASHAs; 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

Table 1.3: Intervention packages under the RMNCH+A Strategy Adolescent health

Adolescent nutrition and folic acid supplementation Adolescent FriendlyHealthServices (AdolescentHealthClinics) Counselingonadolescent reproductive healthand other health issues

Scheme for promotion of menstrual hygiene among rural adolescent girls

Preventive health checkups and screening for diseases, deficiencyanddisability

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

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.

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

Future of Child Health

The nation is addressing child health challenges with greaterdynamismthan ever before. Investments arebeing madeforhealthprogramsandhealthsystemstrengthening. Conditional cash transfers and entitlements are enshrined to stimulate demand for maternal, newborn and child

Introduction to Pediatrics -

healthcare. ICDSisbeing strengthened,particularly inhigh burdendistricts toaddresschildhoodundernutrition. The country is surging ahead with stronger economy and accelerated development. Indiaispoisedtoattainlow child mortality rate, and improve remarkably the health and nutrition status of her children in near future.

Skilled obstetric care and essential newborn care including 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

Package

Facility deliveries by skilled birth attendants Neonatal resuscitation

Essentialnewborn 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