Ghai Essential Pediatrics8th

Clinical assessment and classification. The mother is asked about history of ear pain and ear discharge or pus. The child isexaminedfortenderswellingbehind the ear. Basedonthese clinical findings a child can be classified as mastoiditis, acuteearinfection,chronicearinfectionornoearinfection. Children with mastoiditis are classified as severe illness and referred urgently to hospital. Children with acute ear infection are given oral antibiotics and those with chronic ear infection are advised to keep the ear dry by wicking.

Checking for Ma/nutrition

After assessingfor general danger signs and the four main symptoms, all children should be assessed for malnutrition.

Therearetwomainreasonsforroutineassessmentofnutri­ tional status in sick children: (i) to identify children with severe malnutrition who are at increased risk of mortality and need urgent referral to provide active treatment; and (ii) to identify children with suboptimal nutritional status resulting from ongoing deficits in dietary intake plus repeated episodes of infection and who may benefit from nutritional counseling.

Clinical Assessment and Classification

Visibleseverewasting. Thisisdefinedasseverewastingofthe shoulders,arms,buttocks,andlegs,withribseasilyseen,and indicates presence of marasmus. When wasting is extreme, there are many-folds of skin on the buttocks and thigh. It looksasifthechildiswearingbaggypants.Thefaceofachild withvisibleseverewastingmaystilllooknormal.Thechild's abdomen may be large or distended.

Edema of both feet. The presence of edema in both feet may signal kwashiorkor.

Weightjor-age. Plotting weightfor age in the growth chart, based on reference population, helps to identify children with low (Z score less than -2) or very low (Z scoreless than -3) weight for age, those who are at increased risk of infection and poor growth and development.

Classification ofnutritionalstatus. Usingacombinationofthe simple clinical signs above, children can be classified as severe malnutrition (visiblewastingwithor withoutedema), very low weight or not very low weight.

Checking for Anemia

Allchildren should also be assessed for anemia. The most common cause of anemia in youngchildren in developing countriesisnutritionalorbecauseofparasiticorhelminthic infections.

Clinicalassessment and classification: Palmar pallor can help to identify sick children with severe anemia. Wherever feasible, diagnosis of anemia can be supported by using a simple laboratory test for hemoglobin estimation. For clinical assessment of anemia the color of the child's palm is compared with examiner's own palm. If the skin of the child's palm is pale, the child has some palmar pallor. If the

skin of the palm is very pale or so pale that it looks white, the childhas severe pa/mar pallor. Based on palmar pallor it is classified as severe anemia, anemia or no anemia.

Assessing the Child's Feeding

All children less than 2-yr-old and all children classified as anemia or very low weight need to be assessed for feeding even if they have a normal Z score. Feeding assessment includesquestioningthemotheror caretakeraboutfeeding history. The mother or caretaker should be given appro­ priate advice to help overcome any feeding problems found.

To assess feeding, ask the mother: does she breastfeed herchild(howmanytimesduring the dayandnight),does thechild take anyotherfood orfluids (what food orfluids, how many times a day, how the child is fed, how large are the servings, does the child receive his own serving, who feeds the child) and during the illness, has the child's feeding changed (if yes, how?)

Identify feeding problems When counseling a mother about feeding, one should use good communication skills. It is important to complete the assessment of feeding by referring to age appropriate feeding recommendations and identify all the feeding problems before giving advice. In addition to differencesfromthefeeding recommendations, some other problems may become apparent from the mother's answers. Other common feeding problems are:

Difficultybreastfeeding, useoffeedingbottle, lackofactivefeeding and not feeding well during illness. IMNCI guidelines recommend locally acceptable, available and affordable foods for feeding a child during sickness and health. A sample of such recommendations is given in the IMNCI chart whichneeds to beadapted to local conditions.

Checking Immunization, Vitamin A and

Folic Acid Supplementation Status

The immunization status of every sick child brought to a health facility should be checked. Children who are well enough to be sent home can be immunized.

After checking immunization status, determine if the child needs vitamin A supplementation and/or pro­ phylactic iron folic acid supplementation.

Assessing other Problems

The IMNCI clinical guidelines focus on five main symp­ toms. In addition, the assessment steps within each main symptom take into account several other common prob­ lems. For example, conditions such as meningitis, sepsis, tuberculosis, conjunctivitis, and different causes of fever such as earinfectionand sorethroatareroutinelyassessed within the IMNCI case management process. If the guide­ lines are correctly applied, children with these conditions will receive presumptive treatment or urgent referral. Nevertheless, health care providers still need to consider other causes of severe or acute illness.

Identify Treatment and Treat

All the treatments required are listed in the Identify Treatment column of the Assess and Classify the Sick Child Age 2 Months up to 5 Years (Chart 30.2). All sick children with asevereclassification (pink) arereferred to a hospital as soon as assessment is completed and necessary pre­ referral treatment is administered. If a child only has severe dehydration and no other severe classification, and IVinfusion isavailablein the outpatientclinic, anattempt should be made to rehydrate the sick child. The principles of referral of a sick child are similar to those described for a sick young infant.

Referral of Children Age 2 Months up to 5 Years

Possible prereferral treatment(s) includes:

•For convulsions diazeparn IV or rectally. If convulsions continue after 10 min give a second dose.

•First dose of appropriate intramuscular antibiotic­ chloramphenicol or ampicillin + gentamicin or ceftria­ xone (for severe pneumonia or severe disease; very severe febrile disease; severe complicated measles; mastoiditis). Give oral antibiotic if injectable antibiotics are not available.

•First dose of quinine (for severe malaria) as per national guidelines.

•Vitamin A (persistent diarrhea, measles, severe malnutrition).

•Prevention of hypoglycemia with breast milk or sugar water.

•Oral antimalarials as per guidelines.

•Paracetamol for high fever (38.5°C or above) or pain.

•Tetracycline eye ointment (if clouding of the cornea or pus draining from eye).

•Frequent sips of ORS solution on the way to the hospital in sick children with diarrhea.

If a child does not need urgent referral, check to see if the child needs nonurgent referral for further assessment; for example, for a cough that has lasted more than30 days, or for fever that has lasted seven days or more. These referralsare not as urgent, and othernecessarytreatments may be done before transporting for referral.

Treatment in Outpatient Clinics and at Home

Identify the treatment associated with each nonreferral classification (yellow and green) in the IMNCI chart. Treatment uses a minimum of affordable essential drugs. Following guidelines for treatment need to be followed:

•Counseling a mother/caretaker for looking after the child at home is very important. Good communication skills based on principles of APAC are helpful for effective counseling.

•Give appropriate treatment and advice for 'yellow' and 'green' classifications as detailed in Table 30.2.

Table 30.2: Treatment guidelines for managing sick child In outpatients and at home

Pneumonia, acute ear infection: Give the first dose of the antibiotics in the clinic andteach the mother how to give oral drugs, cotrimoxazole

Dysentery: Give the first dose of the antibiotic in the clinic and teach the mother how to give oral drug, ciprofloxicin for 3 days

Cholera: In areas where cholera can not be excluded, children more than2-year-oldwith severedehydrationshould be given a single dose of doxycycline

Dehydration and persistent diarrhea: Treat 'some' and 'no' dehydration and persistent diarrhea as per standard WHO guidelines

Persistent diarrhea and severe malnutrition, give single dose of vitamin A in the clinic

Measles, give two doses (first dose in clinic and give mother one dose to give at home the next day)

Malaria: Treat as per recommendations Anemia: Give iron folic acid for 14 days

Cough and cold: If the child is 6 months or older use safe home remedies (continue breastfeeding, use honey, tulsi, ginger and other safe local home remedies)

Local infection: Teach the mother or caretaker how to treat the infection at home. Instructions may be given about how to: Treat eye infection with tetracycline eye ointment; dry the ear by wicking to treat ear infection; treat mouth ulcers with gentian violet

For acute diarrhea,persistent diarrheaand dysentery, give zinc (10-20 mg) supplements for 14 days

Counseling a Mother or Caretaker

A child who is seen at the clinic needs to continue treatment, feeding andfluids at home. The child's mother or caretaker also needs to recognize when the child is not improving, or is becoming sicker. The success of home treatment depends on how well the mother or caretaker knows how to give treatment, understands its importance and knows when to return to a health care provider. Some advice is simple; otheradvicerequiresteaching themother or caretaker how to do a task. When you teach a mother how to treat a child, use three basic teaching steps: give information; show an example; let her practice.

•Advise to continue feeding and increase fluids during illness

•Teach how to give oral drugs or to treat local infection;

•Counsel to solve feeding problems (if any)

•Advise when to return (Table 30.3). Every mother or caretaker who is taking a sick child home needs to be advised about when to return to a health facility. The health care provider should (i) teach signs that mean to return immediately for further care, (ii) advise when to return for a followup visit, and (iii) schedule the next well-child or immunization visit.

Table 30.3: Counsel mother when to return

Mother should report immediately if she notices following symptoms

Mother should bring infant for followup visit • Mother should come for scheduled immunization visit •see section on identify treatment

REVISION IN IMNCI GUIDELINES

IMNCI strategy recommends adaptation of clinical and management guidelines based on the local epidemiologic

scenario and management guidelines, which areevidence­ based, pertain to majority of common childhood illnesses, arelocally relevantand feasible. Evaluation and providing justification for revision of these guidelinesisa continuous process. With theavailabilityofmoreepidemiologicaldata on common childhood illnesses in India, there is a possibility of future inclusion of conditions like HIV/ AIDS, dengue fever and asthma at national or state level revision of IMNCI guidelines.

Suggested Reading

Gove S. For the WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bull WHO 1997;75:7-24

Integrated Management of Neonatal and Childhood Illness. Training Modules for Physicians. Ministry of Health and Family Welfare, Govt. of India, 2003

Murray CJL, Lopez AD. The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. In: Global Burden of Disease and Injury Series (vol. I), Cambridge, MA, Harvard School of Public Health, 1996

World Health Organization. Integrated Management of Childhood Illness. WHO/CHD/97.3.A -3.G, WHO, Geneva, 1997

World HealthOrganization.IntegratedManagementof theSickChild. Bull WHO 1995; 73:735-40

World Health Organization. Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for care at the first-referral level in developing countries. WHO, Geneva, 2000

The Constitution of India guarantees equality before the law to all citizens and pledges special protection for children. In 1992, India acceptedtheobligations oftheUN ConventionontheRightsoftheChild (CRC). Inthelasttwo decades, the government has taken several steps towards publicly advancing children's rights. These include the formation of the National Commission for Protection of ChildRights (2005), a National Planof Actionfor Children (2005) and advancing various legislations such as Right to Education (2009) to protect, promote and defend child rights in the country. Physicians need to be familiar with child rights in order to ensure advocacy for children and their families.

United Nations Convention on the Rights of the Child

TheUnitedNationsConvention on the Rights of the Child (UN CRC) is the first legally binding international instru­ ment to incorporate civil, cultural, economic, political and socialrightsforchildren.Itsetsouttheserightsin54articles and two optional protocols. Table 31.1 provides articles of UN CRC that apply to child health. There is sufficient evidence globally to acknowledge that the UN CRC has influenced childrens access to health and well-being.

Every pediatrician can, and should have, adequate knowledge of the rights of children in domains of child survival, identity, development, protection and parti­ cipation. They should understand thebroad social deter­ minants of child health, become trainedin the use of CRC, alignthemselveswithlike-mindedorganizationsinefforts atadvocacy,andlobbytheirlocal,stateandnationalelected representatives to advance child rights.

Promotion and Protection of Child Rights in India

In 2006, the Government of India upgraded to an independent status the Ministry of Women and Child Development, in order to focus on issues concerning the welfareofwomenandchildren.TheNationalCommission

Rajeev Seth

Table 31.1: Articles of the UN Convention on the Rights of the Child that apply to child health

Article Purpose

Article 2 Protection from discrimination

Article 3 Best interests of the child are a primary consi­ deration: The institutions, services and facilities responsible for the care or protection of children shall conform to the standards established by competent authorities

Article 5 Parents are responsible for ensuring that child rights are protected

Article 6 Right to survival and development

Article 9 Right of the child who is separated from one or both parents to maintain personal relations and direct contact with both parents on a regular basis

Article 12 Right of a child to express his/her views, consi­ dering the maturity of the child

Article 14 Freedom of expression including seeking, receiving and imparting information

Article 16 Protection of privacy

Article 17 Access to information from mass media, with protection from material injurious to the child's well-being

Article 18 Assistance to parents with child rearing responsi­ bilities

Article 19 Protection from physical and mental violence, abuse or neglect

Article 20 Special protection to children deprived of their families

Article 22 Protection of children seeking refugee status Article 23 Rights of disabled children to special care Article 24 Right to health and access to health care Article 27 Right to an adequate standard of living Article 28 Right to education

Article 30 Right to the child's own culture and religion Article 31 Participation in leisure and play

Article 34 Protection from sexual exploitation

orProtectionofChildRights,constitutedin2007,provides 'or setting up of state level Commissions meant for protection and promotion of child rights in the country. Besides the institutional, administrative and legislative framework, Indiahasastrongpresenceofnon-Governmental organizations (NGOs) that, along with the media, act as watchdogs to protect humanandchildrights.

Measures for Implementation

Severalpolicies,lawsand programs have beenintroduced to implement the national commitment to child rights. These include:

National Policy for Children (1974). This policy declared children asbeing a supreme national asset.

National Charterfor Children (2003). Thecharteremphasizes the Government'scommitment torightsof children, while enumeratingchildren'sdutiestowardstheirfamilies,society and nation.

NationalPlanofActionforChildren(2005). Thisplancommits to ensuring rights of all children by creating an enabling environment for their survival, growth, development and protection.

National Policy forPersonswithDisabilities (2006). Thepolicy recognizes that a majority of persons with disabilities can lead a better quality of life if they have access to equal opportunities and effective rehabilitation measures.

PolicyFrameworkfor ChildrenwithAIDSinIndia (2007). This policy seeks to address the needs of children affected by HIV/AIDS, by integrating services for them within the existing development and poverty reduction programs.

NationalRehabilitationandResettlementPolicy (2007). Under this policy, no project involving displacement of families can be undertakenwithout a detailed assessment of social impact on the lives of children.

National UrbanHousingandHabitatPolicy (2007). Thepolicy seeks to promote sustainable development of habitat and services at affordable prices in the country and thereby provide shelter to children from disadvantaged families.

National Legislation

The legislative framework for children's rights is being strengthened by the formulations of new laws and amendmentsinold laws. These include the Food Security bill (2011), Right to Free and Compulsory Education Act (2009), Prohibition of Child Marriage Act (2006), the Commissions for Protection of Child Rights Act (2005), Amendments to Juvenile Justice (Care and Protection of Children) Act (2006), Right to Information (2005), the Goa Children (amendment) Act {2005), the Child Labor (Prohibition and Regulation) Act (1986) and Information and Technology (amendment) Act {2008). Two noti­ ficationsin 2006 and2008 expandedthelistof banned and hazardous processes and occupations. New legislations

includethe BillforPreventionofOffencesagainsttheChild and the HIV/AIDS bill.

National Programs

The Government of India is implementing several pro­ grams onsocial inclusion, gender sensitivity, child rights, participation and protection. These programs include: Integrated Child Development Services (ICDS), Kishori Shakti Yojana and Nutrition Programfor Adolescent Girls, Rajiv Gandhi Creche Scheme for children of working mothers, Sislzu Grah (scheme for assistance to homes for children to promote in-country adoption), Dhanalakshmi (conditional cash transfer schemes for the girl child), ProgramforJuvenileJustice,ChildLine(outreachservices for children in need of care and protection through 24 hr tollfreenumber1098), IntegratedChildProtectionScheme, Integrated Program for Street Children, Ujjawala (scheme for prevention of trafficking and rescue, rehabilitation, reintegration and repatriation), Sarva Shiksha Abhiyan (schemetoaddress educationalneeds of 6 to 14-yr-old and bridge social, gender and regional gaps with active community participation), National Program for Edu­ cation of Girlsat elementary level (Kasturba Gandhi Balika Vidyalaya), National RuralHealthMission, Mid-day Meal Program, Jawaharlal Nehru National Urban Renewal Mission, Universal Immunization Program (UIP) and IntegratedManagementofNeonatalandChildhoodIllness (IMNCI).

Role of Pediatricians in Realizing Child Rights

The most basic and crucial child rights are survival and early childhood care, including health care, nutrition, growth, developmentandeducation. Preventionofneglect and protection from exploitation (street children, child labor, trafficking) are complex issues. Parents are often illiterate and ignorant of the rights of their children; awareness of these rights isessential so that they can fight to obtain them.

Pediatricians shouldjoinhandswith committed groups of multidisciplinary child health professionals, nurses, teachers, social workers, psychologist, lawyers, police, judiciary, child rights activists and communityleaders in order to worktogetherand monitor governmental efforts inpromotion and protection of various child rights. They should be able to gather and collateavailable indicators of national child health, address key issues and concerns and facilitate children's participation in projects and policy development. Pediatricians should collaborate with national and international NGOs to initiate advocacy campaigns and media releases in order to change policy, legislations and practice inaccordance with theUN CRC.

CHILD ABUSE AND NEGLECT

Thetermchildabusehasdifferentconnotationsindifferent cultural milieu and socioeconomic situations. The World Health Organization (WHO) defines child abuse or

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maltreatment as forms of physical and/or emotional ill­ treatment, sexual abuse, neglect or negligent treatment or commercial exploitation thatresults in actual or potential harmtothechild'shealth,survival,developmentordignity in the context of a relationship of responsibility, trust or power. Major types of child abuse by caregiver or other adults include:

Physicalabuse. Actsofcommissionbyacaregiverthatcause actual physical harm or have the potential for harm.

Sexual abuse. Those acts where a caregiver uses a child for sexual gratification.

Emotional abuse. The failure of a caregiver to provide an appropriate and supportive environment, including acts that have an adverse effect on the emotional health and development of children.

Neglect. The failure of a parent or guardian to provide for the development of the child,wherehe/sheisin aposition to do so, in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions. Neglect is thus distinguished from circumstances of poverty, in that neglect canoccur only in cases where reasonable resources are available to the caregiver.

Manifestations

Injuries inflicted by a caregiver on a child can take many forms. Patterns of injury to the skin are noted. Skeletal manifestations of abuse include multiple fractures at differentstagesofhealing.Deathinabusedchildrenismost often the consequence of ahead injury orinjury tointernal organs. Aboutone-thirdofseverelyshakeninfantsdieand themajority ofsurvivorssuffer fromlongterm consequen­ cessuch asmentalretardation, cerebralpalsyorblindness. Children who have been sexually abused may exhibit symptoms of infection, genital injury, abdominal pain, constipation, chronic or recurrent urinary tract infections orbehavioralproblems. Manychildrenwilldiscloseabuse tocaregivers or others spontaneously, although theremay beadditionaldirectphysicalorbehavioral signs. Emotional andpsychologicalabusehasreceivedlessattentionglobally due to cultural variations in different countries. Corporal punishmentofchildren,inthe formofslapping,punching, kicking or beating, is a concern in schools and other institutions. Child neglectcanmanifestasfailuretothrive, failure to seek basic health care, immunization and depri­ vation ofeducationand basicnutrition needs. A neglected child is exposed to environmental hazards, substance abuse, inadequate supervision, poor hygiene and abandonment.

Strategies to Reduce Child Abuse and Neglect

Preventing child abuse and neglect should be part of national agenda. In India, abuse and neglect of children is amajorsocialandpublichealthproblem,especiallyamong sociallymarginalized andeconomicallybackwardgroups,

such as children in urban slums, street and work childrenandchildrenofconstructionworkers.Whilecl laborcannotbeabolishedinthepresenceofabjectpove; the Government shouldensure that working children, not exploited. Protection of children against all forms abuse and exploitationis abasic childright. The emplo) must provide for health care for children and ensure th they get time for education.

Acomprehensiveapproachtochildprotectionservices1 rural areas should involve the established system c Panchayati Raj. Thepanchayat officialsshouldberesponsibl for ensuring basic education, nutrition, health care am sanitationforeverychildin thevillage. It shouldbebindinf onthepanchayat toensurethateachchildattendsschoolanci isprotectedfromagrarianandalliedrural occupations as a part of family orindividualchildlabor.

Pediatricians have a significant role in recognizing, respondingtoandreportingchildabuse.Theyareoftenthe first point of contact of a child with abuse and the best advocates forprotection of theirrights. While Indian laws donotmakeitmandatorytoreportchildabuseandneglect, pediatricians should seek assistance from SpecialJuvenile Police units, Child Welfare Committees, Child Line (an emergencytoll-free phone service forchildrenin distress), National and state Commissions for Protection of Child Rights (NCPCR) and NGOs, and direct families to these services. Pediatricians can work with the community, NGOs and governmental administrators to reach out to neglected, deprived and abused children.

Suggested Reading

Aggarwal K, Dalwai S, GaJagali P, Mishra D, Prasad C, Thadhani A, et al. Recommendations on recognition and response to child abuse and neglect in the Indian setting. JndianPediatr 2010;47:49 504

Convention on the Rights of the Child, available from www.unicef. org/crc

Delhj Declaration. http: www.inruanpediatrics.net/delhi declaration 2011.pdf

Srivastava RN. Child abuse and neglect: Asia Pacific Conference and the Delhi Declaration. Jndian Pediatrics 2011;49:ll-2

Study on Child Abuse: India (2007). Ministry of Women and Child Development, Government of Jndia, available from www.wcd.nic.in/ childabuse.pdf

Thjrd and Fourth combined periodic report on theConvention on the Rights of the Child 2011, available from www.wcd.nic.in

ADOPTION

Adoption is an important option for the rehabilitation of destitute and abandoned children or those who cannot be brought up by theirparents due to socialreasons. Medical practitioners play a vital role in influencing health and socialdecisionsoftheiradoptivepatientsandshouldwork closely with counselors and health professionals.

Legal Aspects

'Righttoafamily'isproposedas afundamentalrightbythe UnitedNations.Adoptionagenciesshouldensurethatthese rights are protected. In India, only agencies recognized by

theGovernment candealwithadoptionplacement.Private adoptions, including direct placement by hospitals, maternity and nursing homes, are illegal. Prior to 2000, adoptionwasallowedtoHindusundertheHinduAdoption andMaintenanceAct;otherreligiousgroupsweregoverned by the Guardianship and Wards Act. The Juvenile Justice (Care and Protection of Children) Act, passed by the parliament in 2000, enables citizens of all religions the freedomtoadoptaminorchild,irrespectivewhetherhe/she is a single parent. Such adoptive parents may adopt a child of the same sex, irrespective of the number of living biological sons or daughters.

Procedure of Adoption

A child, who has been relinquished by his/her biological parents or foundabandoned,must first bepresentedto the Child Welfare Committee. Under the current law, this committee has the sole authority to declare the child available for adoption. After due investigations, the committee declaresthe child as destituteand available for adoption. Incasethebiologicalparentswanttorelinquisha child, they have to execute a document in favor of the adoptionagency,witnessedbyanyauthorityofthehospital and a relative. A waiting period of two months is given to biological parents to reconsider the decision, following whichthechildis free foradoption.

Prospective Adoptive Parents

A child canbeadoptedbyamarried couplewithinfertility or those voluntarily opting for adoption. Even single persons are eligible to adopt. Couples who have taken a decision to adopt should go to an agency licensed by the state government and the Central Adoption Resource Authority, anautonomousbodyintheMinistryofWomen and Child Development. Only recognized placement agencies can processthe application of abandoned Indian children for in-country and inter-country adoptions.

Applications for inter-country adoption of a childbornin Indiashould be forwarded by an accredited agency of the countryoftheadoptiveparents,toanagencyinIndia,along with all documents to the Central Adoption Resource Authority.

Asocialworkerfromtheadoptionagencyperformspre­ adoptioncounseling,whichincludesprovidingguidelines and support to pre-adoptive parents, helping them make informed decisions. A home study is conducted by a pro­ fessionalsocialworker.Additionally,parentsarerequired to submit a document regarding their healthand financial status. Once the application is approved, a suitable child is shownto them. After they acceptthe child, placementis legalized. Theplacementisfollowed up to a period of 3 yr orsuchtimeuntillegaladoptioniscomplete. Theadoptive parents are assured confidentiality and provided support as needed.

Role of the Pediatrician

Families often takepediatricians into confidence and seek theiradvice.Additionally,babiesinplacementagenciesare usually takenforasecondopiniontoapediatrician. Pedia­ tricians cancounselandteachfamiliesabout theprocessof adoption. A supporting and understanding attitude encourages adoptive parents to overcome their fears. The physician should examine the child carefully and explain to the adoptive parents the diagnoses, if any, and their prognosis. Theyshould ensurethatall essentialtests(such as HIV, hepatitis B) witha windowperiodare repeated at 3 and 6 months before placement. Parents who wish to relinquish their children due to any reason should be counseled aboutthecorrect procedure so as to ensure that childrenarenotleft inpublicplacesorunhealthysurround­ ings, which may be unsafe and traumatizing.

Suggested Reading

Central Adoption Resource Agency; www.adoptionindia.nic.in

Abdominal pain 286 chronic 289 common causes 287 red flag signs 290

related to functional gastrointestinal disorders 290

Abdominal tuberculosis 305 Accredited social health activist

(ASHA) 2,4 Accidents 696 Acid-base disorders 83

algorithm 83 Acid-base equilibrium

compensation for primary disorders 83 regulation 83,84

renal regulation of 84 Acne vulgaris 682 Acute diarrhea

assessment 292,293 causes 291

clinical findings 291 dehydration 292 drug therapy 296

laboratory investigations 292 management 293,295

oral rehydration solution 294 prevention 296

treatment 294,295

zinc supplementation 295

Acute disseminated encephalomyelitis 569 Acute flaccid paralysis 592

differential diagnosis of 592 surveillance 592

Acute glomerulonephritis 474 etiology 474

indications for renal biopsy 474 Acute hemiplegia of childhood 577

causes 577

clinical features 577 management 578

Acute kidney croup injury 487 clinical features 487 complications 489

definition 487 dialysis 491 etiology 487 evaluation 487, 492 investigations 488 management 488 newborn 491 staging 487

Acute laryngotracheobronchitis,see Croup Acute liver failure,see Liver failure

Acute lyrnphoblastic leukemia 599,600 chemotherapy protocol for 603 clinical presentation 601

differential diagnosis 601 Down syndrome 601,605 evaluation 602 management 602,603,604

Aspergillosis 260 Asthma,bronchial 382,389

classification of severity 387,391 clinical features 383

diagnosis 383,389 management 384,390,747 pathology 382,383 pharmacotherapy 385

step wise treatment 386,387 Asymmetric tonic neck reflex 143 Ataxia-telangiectasia 186,580,586 Ataxia 579

acute cerebellar 579 causes 579 Friedreich 580

Atopic dermatitis 680 Atrial septa! defect 413

assessment of severity 414 complications 414 physiology 413

treatment 414

Attention deficit hyperactivity disorder 59 clinical features 59

diagnosis 59 management 60

Autistic disorder 61

Autoimmune hemolytic anemia 340 clinical features 340

cold reactive autoantibodies 340 management 340

warm reactive autoantibodies 340 Autoimmune liver disease 321 Autosomal dominant disorders 641 Autosomal recessive disorders 641

Bacillus Calmette Guerin (BCG) 190 Bag and mask ventilation 129,712 Baggy pants appearance 99

Bangle test 97 Barlow maneuver 141 Bartter syndrome 501 Basophilia 357

BCG test 254

Becker muscular dystrophy 595 Behavioral disorders 57

Beh<;et disease 634

Benign intracranial hypertension,see Pseudotumor cerebri

Biotin 120

Birthmarks,vascular 679 Bladder catheterization 734 Bleeding 349

clinical evaluation 349,351 differences between platelet and coagulation disorders 350 laboratory investigations 350

Block skills 51

Blood component therapy 355 Blood gas analysis 374

Body mass index (BMI) 13 for age 26,32-34

Bone age 11

Bone marrow aspiration,biopsy 736 Bone marrow failure,see Aplastic anemia Bone tumor 619

Bradyarrhythmias,see Arrhythmia Brain abscess 573

Brain tumors 571,612,613 brainstem 571 cerebellar 571

clinical presentation 613 diagnosis 614 supratentorial 572 treatment 614

Breast milk benefits of 150

composition of 153 expressed 155

Breastfeeding 90,150,151,154 drug therapy 180 physiology 151

principles 90 problems in 154 technique of 153

Breath holding spells 58 Bronchial asthma,see Asthma Bronchiectasis 392 Bronchiolitis 381

causes 382

clinical features 381 differential diagnosis 382 treatment 382

Bronchodilators 386,747 Bronchopulmonary dysplasia 171 Bronchoscopy 373

Brucellosis 259

Bruton agammaglobulinemia 186 Budd-Chiari syndrome 320 Bulimia 57

Bullous impetigo 688 Bums 705

Calcium 79,521 corrected 80

disorders of metabolism 521 Calcitonin 79

Calcium sensing receptor 79 Cancer survivorship 623 Candidiasis 366,694

invasive 259

Caput succedaneum 141

Cardiac catheterization,diagnostic 409 Cardiomyopathy 447

Cardiopulmonary resuscitation,drugs 714 Cardiovascular disease,preventing

adult 462

Carotenemia 111 Carrier screening 645 Cataract 670 Catch-up diets 106

Catheterization of bladder 734 Celiac disease 301

diagnosis 301 treatment 307

Cellulitis 688

Cephalohematoma 141 Cerebral edema 547 Cerebral palsy 581

cerebellar 582 diagnosis 582 etiopathogenesis 581 extrapyramidal 582 hypotonic (atonic) 582 management 583

mixed 582 spastic 582

Coarctation of aorta 431 clinical features 432 complications 432 hemodynamics 431 treatment 432

Constrictive pericarditis,chronic 450 Corrected TGA 426

Cyanosis and high pulmonary flow 428 Cyanotic heart disease 420

with pulmonary arterial hypertension 428 Congenital heart disease,see also individual

defects 404,409 acyanotic 413

catheter-based interventions 410 catheter interventions for 410 complications of 410

cyanosis and high pulmonary flow 428 cyanotic heart disease with pulmonary arterial hypertension 428

cyanotic spells 411

duct dependent lesions 405 Fallot (VSD-PS) physiology 404 hemodynamic classification 403 infective endocarditis in 411 Nadas' criteria 406

natural history 411 obstructive lesions 429

single ventricle physiology 405 spontaneous closure of defects 412 surgery 409

treatment 409 Chandipura virus 239 Charcoal,activated 699

Chediak-Higashi syndrome 358 Chest circumference 12

Chest compressions 130,710 Chickenpox,see Varicella Chikungunya 229

clinical features 229 diagnosis 229 treatment 229

Child abuse 769,770 manifestations 770 Child mortality 2,3 Choanal atresia 366 Choledochal cyst 288

Cholelithiasis 287

Cholesteatoma 360 Cholesterol 90 Chromosomal disorders 636 Chronic bullous disease 686 Chronic diarrhea 299,303

approach 299,300 causes 299

Chronic glomerulonephritis 483 Chronic granulomatous disease 358 Chronic hepatitis B 322

clinical features 322 management 322 prevention 323

Chronic hepatitis C clinical features 323 epidemiology 323 treatment 323

Chronic inflammatory demyelinating polyradiculopathy 591

Chronic kidney disease 493 anemia 495

cause 493

clinical features 494 hypertension 495 investigations 494 management 494,496 mineral bone disease 495

Chronic liver disease 316 causes 316, 326 cUnical features 316 investigation 317

Chronic lung disease 171

Chronic myeloid leukemia (CML) 607 adult variety 607

juvenile 608

Chronic suppurative otitis media 60 Cleft Iip 177

Cleft palate 177, 366 Cobalarnin (vitamin B12) 119 Cold chain 205

Cold stress 144 Collodion baby 677 Coma 561

grades 561 investigations 562 treatment 563

Combination vaccine 203 Common cold 374

Common variable immunodeficiency 186 Complementary feeding 91

Conduct disorders 62

Congenital abnormalities of kidneys and urinary tract 505

Congenital adrenal hyperplasia 526 21-hydroxylase deficiency 526, 527 other variants 528

Congenital diaphragmatic hernia 138, 178 Congenital heart disease 400

classification 403 diagnostic approach 405 etiology 400

genetic conditions 401 Congestive cardiac failure 396

causes 397

diastoUc dysfunction 396 prognosis 400

time of onset of 397 treatment of 398

Congenital nephrotic syndrome 482 Congenital rubella syndrome 272 Congenital syphilis 272

Congenital toxoplasmosis 272 Conjunctivitis 162,668 Constipation 283

causes 284, 285 management 284

Constitutional growth delay 37 Convulsions, see Seizures Copper 122

Cough 371 acute 371

chronic or recurrent 371 diagnostic approach 394 Cow milk protein allergy 301

Cransynostosis 41 Creatinine clearance 469

Crescentic glomerulonephritis 476 Cretinism,endemic 519 Crigler-Najjar syndrome 312 Crimean hemorrhagic fever 239 Crohn disease 304

Croup 368,376 congenital causes 369

differential diagnosis 376 management 376 spasmodic 376

Cryptococcosis 260

Cryptorchidism 540 Cushing syndrome 523

evaluation 524 laboratory findings 524 management 525

Cyanotic spells 411 Cyclic vomiting 280 Cystic fibrosis 393

clinical manifestations 393 diagnosis 393 management 393

Cystic kidney diseases 507 Cysticercosis 277, see Neurocysticercosis Cystinosis 500

Cystinuria 503 Cytomegalovirus infection 272

Daily nutrient requirements 89 Dentition 11

Degenerative brain disorders 583 Dehydration

clinical assessment 73

in severe malnutrition 102, 104 severe 73

some 73 therapy 72

DemyeU.nating disorders 580 Dengue infections 224

algorithm 227,228 clinical manifestations 225 differential diagnosis 225 epidemiology 224 management 226,227 monitoring 228 prevention 228

prognosis 228 severe 226

Dengue shock syndrome 226 Depressor anguli oris muscle,

absence of 138 Dermatophytoses (ringworm) 692 Development

assessment 53 domains of 44 factors affecting 42 fine motor 49,50 gross motor 45, 49 language 52,53 milestones 49-55 normal 42

personal and social 52 quotient (DQ) 54

red flags signs 55

scales 55,56

vision and hearing 53 Developmental dysplasia of hips

(DOH) 139, 141 Development screening tests 55

CAT/CLAMS 56 Denver 56

Goodenough-Harris drawing 56 Phatak's Baroda 56 Trivandrum development 56

Development surveillance 56 Dhatura (belladonna) poisoning 702 Diabetes insipidus 519

nephrogenic 501 Diabetes mellitus 541 classification 541 clinical features 542 complications of 545 diagnosis 542, 545 epidemiology 541 insulin therapy 543

maternal 181 nutrition therapy 544 sick day care in 544 treatment 542, 545 type 2 544

Diabetic ketoacidosis 546 clinical features 547 laboratory evaluation 547 management 547

Diaper dermatitis 682 Diaphragmatic hernia 178 Diarrhea

acute,see acute Diarrhea chronic 299

persistent 297 Diet

balanced 91 normal 90

Dietary standards 90 DiGeorge syndrome 185 Digoxin,dose of 399 Dilated cardiomyopathy 447 Diphtheria

clinical features 242 diagnosis 242 management 242 prevention 242 vaccines 193

Disorders of sexual differentiation 537 classification 538

evaluation 539 management 539

Disruptive behavior disorders 62 Disseminated intravascular coagulation 353

causes 354

clinical and laboratory evaluation 354 diagnosis 355

treatment 354 Diuretics 399,748 Down syndrome 637

associated abnormalities 638 clinical features and diagnosis 638 counseling 639

cytogenetics 638 management 638 prenatal diagnosis 639