IAP

Textbook
of Pediatrics
4th Edition

IAP
Textbook
of Pediatrics
4th Edition
Editor-in-Chief
A Parthasarathy

Professor of Pediatrics, Madras Medical College, and

Deputy Superintendent, Institute of Child Health and Hospital for Children, Chennai (Retired)
National President, IAP 1997, Regional Advisor, APPA, 199799
Founding Editor-in-Chief, Indian Journal of Practical Pediatrics
Contributory Editor, ColorAtlas of Tropical Pediatrics, American Academy of Pediatrics 2009

Executive Academic Editor

PSN Menon

Sub-Dean, Professor of Pediatrics, Division of Pediatric Endocrinology and

Officer in-Charge Genetic Unit, All India Institute of Medical Sciences, New Delhi (Retired)
Consultant and Head, Department of Pediatrics
Jaber Al-Ahmed Armed Forces Hospital, Kuwait

Senior Editors

RK Agarwal

Naveen C Thacker

Deepak Ugra

President, IAP 2006

Senior Consultant Pediatrician and Director
Deep Children Hospital and Research Centre
Gandhidham (Kutch), Gujarat, India

Piyush Gupta

Panna Choudhury

President, IAP 2009

Editor-in-Chief, Indian Pediatrics 2005-7
Consultant Pediatrician
Lok Nayak Hospital, New Delhi, India

President, IAP 2008

Senior Consultant Pediatrician and Director
RK Hospital
Udaipur, Rajasthan, India

President Elect, IAP 2010

Consultant Pediatrician
Lilawati Hospital and Research Centre, Mumbai
Guru Nanak Hospital and Research Centre, Mumbai

Senior Academic Editors

Professor of Pediatrics
University College of Medical Sciences
New Delhi, India
Editor-in-Chief, Indian Pediatrics 2008-10

MKC Nair

Professor of Pediatrics and Clinical Epidemiology

Director, Child Development Centre
Medical College, Thiruvananthapuram, Kerala, India
President IAP 2004, President INDIACLEN 2005-7

Executive Editors
Rohit C Agrawal

Tanmay Amladi

Honorary Secretary General, IAP 2007-08

Director, Chandra-Jyoti Children Hospital
Mumbai, Maharashtra, India

Treasurer, IAP 2007-8, Honorary Neonatologist

Nowrosjee Wadia Maternity Hospital and NICU
Parel, Mumbai, Maharashtra, India

Academic Editor
K Nedunchelian

Editor-in-Chief, Indian Journal of Practical Pediatrics

Assistant Professor of Pediatrics, Madras Medical College
Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu, India

JAYPEE

Published by
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IAP Textbook of Pediatrics , 4th edition
2009, Indian Academy of Pediatrics, Kailas Darshan, 1st Floor, Kennedy Bridge, Nana Chowk, Mumbai 400 007, India
Tel: (022) 23887906/23887922/23889565 Fax: (022) 23851713
E-mail: [email protected]; [email protected]
Websites: www.iapindia.org/www.ijpp.org/www.indianpediatrics.net/www.iapdrugformulary.com
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the Indian Academy of Pediatrics and
the publisher.
This book has been published in good faith that the material provided by editors is original. Every effort is made to ensure accuracy of
material, but the publisher, printer and Indian Academy of Pediatrics will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 1999, 2000
Second Edition: 2002, 2003
Third Edition: 2006
Revised Reprint 2007
Fourth Edition: 2009
ISBN 978-81-8448-580-6
Typeset at JPBMP typesetting unit
Printed at Ajanta

To
The Children of India
Whose Care, Survival and
Development are Our Concern

IAP Textbook of Pediatrics

This textbook has covered all aspects of child health contributed by reputed authors, in addition to
National Health Programs. Thus, it has fulfilled all the criteria of a reader friendly treatise
Dr Uday Bodhankar
President, IAP 1995
President, ISTP 1999-2001
Nagpur
Several luminaries who are past and present teachers have contributed their might which has made the
present textbook a novel production in many aspects
Prof YC Mathur
President, IAP 2001
Hyderabad
Indeed it is a millennium gift to students and practitioners in a well written and well presented
comprehensive format covering A to Z in Pediatric care
Dr Swati Y Bhave
President, IAP 2000
New Delhi
Teachers of Pediatrics will find in this book guidelines for the course contents in undergraduate and
postgraduate medical education. Medical students will find readable and reasonably detailed, yet concise
information in this book, not only to complete the course and pass the final examination, but also to guide
them during their clinical career as intern, house surgeon and medical practitioner
Prof T Jacob John
President, IAP 1999
Vellore
I hope this textbook finds an appropriate place in the students' and practitioners' bookshelf. I sincerely
wish that this book is also suitable for undergraduates and postgraduates
Prof MR Lokeshwar
President, IAP 1998
Mumbai

Contributors
Aditi Sinha
Senior Research Associate
Department of Pediatrics
All India Institute of Medical
Sciences, New Delhi 110 029
Residence
5B Srijan Apartments
B 9/8 Sector 62
Noida
Uttar Pradesh
Email: [email protected]
Advani SH
Director
Department of Medical Oncology
Jaslok Hospital, Peddar Road
Mumbai
Maharashtra
Residence
201 Satyam Shivam Sunderam
Ghatkopar
Mumbai 400 077
Maharashtra
Email: [email protected]
Agarwal DK
D-115 Sector 36, Noida
Gautam Budh Nagar 201 301
Uttar Pradesh
Agarwal KN
D-115 Sector 36, Noida
Gautam Budh Nagar 201 301
Uttar Pradesh
Email: [email protected];
[email protected]
Agarwal R
Department of Pediatrics
BJ Wadia Hospital for Children and
Institute of Child Health
Parel, Mumbai 400 012
Maharashtra

Agarwal RK
Consultant Child Specialist
RK Hospital
5A Madhuban
Opposite RSEB Window
Udaipur 313 001, Rajasthan
Email: [email protected];
[email protected]
Ajit Kumar
3/6/69/B/20/4/A
Avanti Colony
Near Skyline Theatre
KB Lal Road, Bashirbag
Hyderabad 500 029
Andhra Pradesh
Amdekar YK
151 Tushar 1st Floor
14th Road Chembur
Mumbai 400 071, Maharashtra
Email: [email protected]
Amit Upadhyaya
Consultant Hematologist
Sunflag-Pahuja Center for
Blood Disorders
Sunflag Hospital, Faridabad
Haryana
Email: [email protected]
Amrish Vaidya
Consultant Pediatric Surgeon
Kokilaben Dhirubhai Ambani
Hospital, Andheri West
Mumbai 400 053
Maharashtra
Residence
5E Sundatta Apartments
10A Mount Pleasant Road
Mumbai 400 006
Maharashtra
Email: [email protected]

Anand N Pandit
British Council Building
917/1 Fergusson College Road
Pune 411 004, Maharashtra
Email: [email protected]
Anand RK
55 Kavi Apartments, Worli
Mumbai 400 018, Maharashtra
Email: [email protected]
Anandam R
Professor of Pediatric Neurology (Retd)
Consultant Neurologist
PRS Hospital, Killippalam
Thiruvananthapuram, Kerala
Residence
RAJCOT
Thycaud
Thiruvananthapuram 695 014
Kerala
Email: [email protected]
Anil Mokashi
Ramabai Maternity General
and Childrens Hospital
Baramati, Pune 413 102
Maharashtra
Anil Sachdev
63/12
Old Rajinder Nagar
New Delhi 110 060, Delhi
Email: [email protected]
Anita Khalil
The Heart Centre
2 Ring Road
Lajpat Nagar IV
New Delhi 110 024, Delhi
Email: [email protected]

IAP Textbook of Pediatrics

Anju Aggarwal
Reader in Pediatrics
University College of Medical
Sciences and Guru Tegh Bahadur
Hospital
Delhi
Residence
Flat # 3C Block C2B, Janakpuri
New Delhi 110 058, Delhi
Email: [email protected];
[email protected]
Anju Virmani
C 6/6477
Vasant Kanj
New Delhi 110 070
Email: [email protected]
Anupam Sachdeva
C-107 Neelambar Apartment
Near Sainik Vihar
Shakurbasti
New Delhi 110 034
Email: [email protected]
Anupama Borker
Consultant Pediatric
Hemato-Oncologist
SL Raheja Hospital
Mahim, Mumbai
Maharashtra
Residence
22 Kaustubh Plot # 8
Bandra Reclamation
Bandra (West)
Mumbai 400 050
Maharashtra
Email: [email protected]

Archana Sathe
Om Padmalaya
1123/A Shukrawar Peth
Opposite Hirabag
Pune 411 002
Maharashtra

Ashish R Bavdekar
11 Yeshwant Nagar
Ganeshkhind Road
Pune 411 007
Maharashtra
Email: [email protected]

Armida Fernandez
53 Sea Springs
BJ Road, Band Stand
Bandra (West)
Mumbai 400 050
Maharashtra
Email: [email protected]

Ashok Gupta
25 Chetak Marg
Near JK LON Hospital
Jaipur 302 004, Rajasthan
Email: [email protected]

Arun Gupta
BP 33, Pitampura
New Delhi 110 034, Delhi
Email: [email protected]
Arun Kumar Gupta
Professor and Head
Department of Radiodiagnosis
All India Institute of
Medical Sciences, New Delhi 110 029
Email: [email protected];
[email protected]
Arun Phatak
102 Ambica Apartments
Shanker Tekri
Dandia Bazaar
Vadodara 390 001
Gujarat
Email: [email protected]

Anurag Tomar
4 Govind Marg
Jaipur 302 004
Rajasthan
Email: [email protected]

Arunmozhi T
Assistant Professor of
Community Medicine
Madras Medical College
Residence
8I Block, 2nd Main Road
Chennai 600 102
Tamil Nadu

Archana S Kher
6/A Anand Bhavan
36th Road, TPS III
Bandra (West)
Mumbai 400 050
Maharashtra
Email: [email protected]

Arvind Bagga
Professor of Pediatrics
Division of Nephrology
All India Institute of Medical
Sciences, Ansari Nagar
New Delhi 110 029
Email: [email protected]

Ashok K Deorari
Professor of Pediatrics
Division of Neonatology
All India Institute of
Medical Sciences
New Delhi 110 029
Residence
D-II/22, Ansari Nagar
New Delhi 110 029, Delhi
Email: [email protected];
[email protected]
Ashok K Gupta
50 B/D, Gandhinagar
Jammu 180 004
Jammu and Kashmir
Email: [email protected]
Ashok K Patwari
Readers Flat # 4
LHMC Campus
Bangla Sahib Road
New Delhi 110 001
Email: [email protected];
[email protected]
Ashok S Kapse
Kapse Children Hospital
1st Floor, Akshar Complex
B/H Rang Upvan, Makkaipool
Surat 395 001, Gujarat
Email: [email protected]
Babu George
Medical Superintendent
Child Development Centre
Medical College Campus
Thiruvananthapuram,
Kerala

Contributors XI
Balachandran A
F/177 Plot # 235
Anna Nagar, Chennai 600 102
Tamil Nadu
Email:[email protected];
[email protected]
Baldev S Prajapati
Aakanksha Children Hospital
Opposite Tulsishyam Flats
Nava Vadaj Road
Ahmedabad 380 013
Gujarat
Email: [email protected]
Balvir S Tomar
4 Govind Marg
Jaipur 302 004
Rajasthan
Banapurmath CR
DOOR # 176 3rd Main Road
PJ Extension
Devangere 577 002, Karnataka
Email: crbanapurmath@hotmail. com
Banerjee SR
8 Jessore Road, Dum Dum
Kolkata 700 028, West Bengal
Email: [email protected];
[email protected]
Baskar PK
Director
Sri Viveka Institute of Dental
Sciences
54, GN Chetty Road, T Nagar
Chennai 600 017, Tamil Nadu
Bhandari B
90/L Road, Bhupalpura
Udaipur 313 001, Rajasthan
Bhandari NR
C-32 Koh-e-Fiza
BDA Colony
Bhopal 462 001
Madhya Pradesh
Email: [email protected];
[email protected]

Bharat Agarwal
A1101 Jagat Vidya CHS
Behind Guru Nanak Hospital
Bandra-Kurla Complex
Bandra (East)
Mumbai 400 051
Maharashtra
Email: [email protected]
Bharat Dalvi
Division of Pediatric Cardiology
Department of Cardiology
King Edward VII Memorial Hospital
Mumbai, Maharashtra
Bhaskar Raju B
# 11 Sringeri Mutt Road
Ramkrishna Nagar
Chennai 600 028
Tamil Nadu
Email: [email protected]
Bhavuk Garg
Senior Research Associate
Department of Orthopedics
All India Institute of
Medical Sciences
New Delhi 110 029
Residence
525 Masjid Moth Doctors Hostel
Masjid Moth
New Delhi 110 049
Email: [email protected]
Bina Ahuja
Clinical Specialist
National Polio Surveillance Project
India-WHO
RK Khanna Tennis Stadium
Africa Avenue
New Delhi 110 029
Residence
E 285 Narain Vihar
New Delhi 110 028,
Email: [email protected];
[email protected]

Brijesh Arora
Associate Professor
Pediatric Oncology
Tata Memorial Hospital
Ernest Borges Marg
Parel, Mumbai 400 012
Maharashtra
Residence
House No 7 Anand Bhavan
Bhula Bhai Desai Road
Near Breech Candy Hospital
Mumbai 400 026
Email: [email protected]
Chandan J Das
Senior Research Associate
Department of Radiodiagnosis
All India Institute of Medical
Sciences
New Delhi 110 029
Email: [email protected]
Choudhry VP
A-26 Shivalik
Malviya Nagar
New Delhi 110 017, Delhi
Email: [email protected]
Dadhich JP
23 Canara Apartments
Sector 13, Rohini
New Delhi 110 085, Delhi
Email: [email protected]
Dagar KS
Consultant
Department of Pediatrics and
Congenital Heart Surgery
Escorts Heart Institute and
Research Centre, Okhla Road
New Delhi
Dani VS
Gandhi Sagar (East)
Mahal
Nagpur 440 002
Maharashtra
Email: [email protected]

XII

IAP Textbook of Pediatrics

Deepak Bansal
House # 1334, Sector 19
Faridabad, Haryana
Email: [email protected]
Deepak Seth
Department of Pediatrics
Himalayan Institute of
Medical Sciences
Post Doiwala, Dehradun 248 140
Uttarakhand
Email: [email protected]
Deepak Ugra
A-402/403 Sausalito
Kia Park Prathamesh Complex
Veera Desai Road, Andheri (West)
Mumbai 400 053
Email: [email protected]
Desai AB
1004 Panchtirth
Jodhpur Char Rasta, Satellite
Ahmedabad 380 015, Gujarat
Email: [email protected]
Digant D Shastri
Killol Children Hospital
303-304 Takshashila Apartments
Majuragate, Surat 395 002
Gujarat
Email: [email protected]
Dilip Mukherjee
9/1 Ramnath Pal Road
Kolkata 700 023
West Bengal
Email: [email protected]
Divya Prabhat
Ear Nose Throat Specialist and
Head and Neck Surgeon
Jeevak Hospital
Opposite Asiad Bus Stand
Dadar (East) Mumbai (East)
Dubey AP
6E MS Flats
Mint Road Complex
New Delhi 110 002
Email: [email protected];
[email protected]

Dutta AK
Flat # 8
Lady Hardinge Medical College
Campus, New Delhi 110 001, Delhi
Email: [email protected]
Gadadhar Sarangi
Professor
Department of Pediatrics
Hitech Medical College, Pandara,
Bhubaneswar, Orissa
Residence
C/o Dr Laxmi Kanta Mohapatro
At Telisahi (Parijat Lane)
Ranihat, Cuttack 753 001, Orissa
Email: [email protected];
[email protected]
Ganessan KM
13 Chinna Mudali Street
Gudiyattam
Gudiyattam 632 602, Tamil Nadu
Email: dr_kmganessan@ rediffmail. com
George Moses L
Prof of Microbiology (Retd)
Director
Kilpauk Laboratory Services
27(12) Vasy Street
Near Ega Theatre
Kilpauk, Chennai - 600 010

Gowrishankar NC
Assistant Professor
Department of Pulmonology
Institute of Child Health and
Hospital for Children
Chennai 600 008
Residence
12/A Balasubramaniam Street
Mylapore
Chennai 600 004
Tamilnadu
Gupta BD
Vrandwan 120
Bhagat Ki Kothi Extension
Near Asha Hospital
Opposite New Campus
Pali Road, Jodhpur 342 001
Rajasthan
Email: [email protected]

Guruprasad G
2164 Veda IV Main X Cross
MCC A Block
Devangere 577 004
Karnataka
Email: [email protected];
[email protected]
Harish Kumar
12/406 Sunder Vihar
New Delhi 110 041
Email: [email protected];
[email protected]
Indra Shekhar Rao M
Former Medical Superintendent
Institute of Child Health and
Niloufer Hospital, Hyderabad
Andhra Pradesh
Residence
Indra Prastha
Plot # 106
Abhinav Nagar
Secunderabad 500 025
Andhra Pradesh
Email: [email protected]
Iyer KS
Senior Consultant and Head
Department of Pediatrics and
Congenital Heart Surgery
Escorts Heart Institute and
Research Centre, Okhla Road
New Delhi
Jacob John T
Thekkekara 439 Civil Supplies
Godown Lane
Kamalakshipuram, Vellore
North Arcot 632 002
Tamil Nadu
Email: [email protected]
Jain MK
Quarters # 2
Opposite District Hospital
Vidisha, Madhya Pradesh
Jayakar Thomas
Senior Consultant Dermatologist
Kanchi Kamakoti Childs TRUST
Hospital and Mehtas Hospital
Chennai, Tamil Nadu
Residence
2 West Mada Church Road
Royapuram
Chennai 600 013, Tamil Nadu
Email: [email protected]

Contributors XIII
Jayashree A Mondkar
22/24 Vaibhav Apartments
SK Bole Road, Dadar
Mumbai 400 028
Maharashtra
Email: [email protected];
[email protected]
Jayashree Muralidharan
127 Type V PGI Flats
Sector 24-A
Chandigarh 160 023
Email: [email protected]
Jaydeep Choudhury
Assistant Professor
Department of Pediatrics
Institute of Child Health
Kolkata, West Bengal
Residence
95/2 Ballygunge Place
Kolkata 700 019
West Bengal
Email: drjaydeep_choudhury@
yahoo.co.in
Jnanindra Nath Behera
Associate Professor of Pediatrics
SCB Medical College
Cuttack 753 007, Orissa
Email:[email protected]
Joshi NC
19-B Kumkum Apartments
SV Road, Vile Parle (West)
Mumbai 400 056, Maharashtra
Jugesh Chhatwal
Department of Pediatrics
CMC Hospital
Ludhiana 141 008, Punjab
Email:[email protected]
Kabra SK
Additional Professor
Department of Pediatrics
All India Institute of Medical
Sciences
New Delhi 110 029
Email: [email protected]

Kalpana D
Assistant Professor
Department of Pediatric Neurology
SAT Hospital
Medical College
Thiruvananthapuram 695 004,
Kerala
Residence
KALPANA
NSP Nagar
Kesavadasapuram
Thiruvananthapuram 695 004,
Kerala
Email: [email protected]
Kamath SS
XL/5152 TD Road (North End)
Kochi, Ernakulam 682 035
Kerala
Email: [email protected]
Karmarkar DP
1165 Harbhat Road
Karmarkar Wada
Sangli 416 416, Maharashtra
Ketan Praveen Parikh
Consultant Pediatric Surgeon and
Pediatric Laparoscopist
Kokilaben Dhirubhai Ambani
Hospital, Andheri West
Mumbai 400 053
Maharashtra
Residence
B-404 Kukreja Palace
Vallabhbaug Lane Extension
Ghatkopar (East)
Mumbai 400 075
Maharashtra
Email: [email protected]
Keya R Lahiri
Professor and Head
Department of Pediatrics
Seth GS Medical College and
KEM Hospital
Parel, Mumbai 400 012
Residence
Vijay Kunj B/10
JN Road, Santacruz (East)
Mumbai 400 055
Maharashtra
Email: [email protected]

Kochupillai N
Director, Medical Research
MS Ramaiah Medical College and
Hospitals, MSR Nagar, MSRIT PO
Bengaluru 110 029, Karnataka
Email: [email protected]
Kotwal PP
Professor and Head
Department of Orthopedics
All India Institute of
Medical Sciences
New Delhi 110 029
Residence
C 1/19 Ansari Nagar
New Delhi 110 029
Email: [email protected]
Krishan Chugh
J-5/169
Rajouri Garden
New Delhi 110 027
Email: [email protected]
Kulkarni ML
2373 MCC A Block
Devangere 577 004
Karnataka
Email: [email protected]
Kumud P Mehta
Mother and Child Hospital
Gita 2nd Floor
P Ramabai Road
Gamdevi
Mumbai 400 007
Maharashtra
Email: [email protected]
Kundan Kumar Mittal
227-B Medical More
Model Town
Rohtak 124 001, Haryana
Email: [email protected]
Lokeshwar MR
19/54 Welfare Mansion
Sion, Mumbai 400 022
Maharashtra
Email: [email protected];
[email protected]

XIV

IAP Textbook of Pediatrics

Madhulika Kabra
Additional Professor
Genetic Unit
Department of Pediatrics
All India Institute of Medical Sciences
New Delhi 110 029, Delhi
Email: [email protected];
[email protected]
Madhusudhana SN
Department of Virology
National Institute of Mental Health
and Neurological Sciences
Bengaluru, Karnataka
Mahadeviah M
518 Rajmahal Vilas Extension
Sadashiv Nagar
Bengaluru 560 080
Karnataka
Email: [email protected]
Maiya PP
343 25th Cross
9th Main Road
Banashankari II Stage
Bengaluru, Karnataka
Email: [email protected]
Major K Nagaraju
Senior Consultant in
Pediatric Allergy
Kanchi Kamakoti Childs TRUST
Hospital
12 A Nageswara Road
Nungambakkam
Chennai 600 034
Email: [email protected]
Malathi Sathiyasekaran
# 16th Cross Street
Indira Nagar
Chennai 600 020
Tamil Nadu
Email: [email protected]
Mamta V Manglani
A-202 Casuarina, Evershine Greens
New Link Road, Andheri (West)
Mumbai 400 102, Maharashtra
Email: [email protected]

Manju Mehta
Professor of Clinical Psychology
Department of Psychiatry
All India Institute of Medical Sciences
New Delhi 110 029
Email: [email protected]
Manorama Verma
8 SF HIG Flats
Bhai Randhir Singh (BRS) Nagar
Ferozepur Road
Ludhiana, Punjab
Marwaha RK
Professor of Pediatrics
Incharge, Division of Pediatric
Hematology-Oncology
Advanced Pediatric Centre
Postgraduate Institute of Medical
Education and Research
Chandigarh 160 012
Email: [email protected]
Mathur RC
4-1-1233/5
Subhodaya Apartments
Bogulkunta, ABIDS
Hyderabad 500 001
Andhra Pradesh
Email: [email protected]
Mayilvahanan Natarajan
Professor and Head
Department of Orthopedic Surgery
Madras Medical College and
Government General Hospital
Chennai 600 003
Tamil Nadu
Residence
4 Lakshmi Street
Kilpauk
Chennai 600 010
Tamil Nadu
Meena P Desai
307 Samudra Mahal
Dr AB Road, Worli
Mumbai 400 018
Maharashtra
Email: [email protected]

Meena R Malkani
F-6 Model House
158 Sion (East)
Mumbai 400 022, Maharashtra
Email: [email protected]
Meenakshi N Mehta
Shaivali C/3 9, BMC Colony
Kag Khan Road, Worli
Mumbai 400 018, Maharashtra
Meharban Singh
A-47 Sector 31, Noida
Gautam Budh Nagar 201 301
Uttar Pradesh
Email: [email protected]
Menon PSN
Consultant and Head
Department of Pediatrics
Jaber Al-Ahmed Armed Forces
Hospital, Kuwait
Residence
W1C 055 Wellington Estate
DLF City Phase V
Gurgaon 122 002, Haryana
Email: [email protected]
Milind S Tullu
Associate Professor
Department of Pediatrics
Seth GS Medical College
KEM Hospital
Parel, Mumbai 400 012
Residence
1 Sankalp Siddhi
Service Road, Kher Nagar
Bandra East
Mumbai 400 051
Nagabhushana S
Visiting Consultant
Columbia Asia Hospital
Hebbal, Bengaluru
Residence
Aditya # 37/22/1
2nd Cross 1st Main
Sundarnagar
Post Gokula
Bengaluru 560 054, Karnataka
Email: [email protected];
[email protected]

Contributors XV
Nair MKC
TC 24/2049
Near Rose House
Womens College Junction
Thycand
Thiruvananthapuram 695 014,
Kerala
Email: [email protected];
[email protected]
Nammalwar BR
2 Main Road, Seetha Nagar
Nungambakkam
Chennai 600 034
Tamil Nadu
Email: [email protected]
Nandini Mundkur
Bangalore Children Hospital
City Centre # 6 Chitrapur
Bhavan 8th Main 15th Cross
Malleswaram
Bengaluru 560 055
Karnataka
Email: [email protected]
Naveen Thacker
Past President, IAP
Deep Children Hospital
Plot 208, Sector 1-A
Opposite Hero Honda Showroom
Gandhidham, Kutch 372 201
Residence
D-70 Shaktinagar
Gandhidham
Kutch 370 201, Gujarat
Email: [email protected]
Neeraj Jain
Associate Professor
Department of Pediatrics
Himalayan Institute of Medical
Sciences
Jolly Grant, Dehradun 248 140
Uttarakhand
Residence
A1/2 Maa Ganga Vaatika
Rishikesh, Uttarakhand
Email: [email protected]

Niranjan Shendurnikar
C/21 Nandigram # 2
Sindhwai Maata Road
Vadodara 390 004, Gujarat
Email: [email protected]
Nitin Chandra Mathur
4-1-1233/5 Subhodaya
ABIDS
Hyderabad 500 001
Andhra Pradesh
Email: [email protected]
Nitin Shah
186-A Vaswani Villa
1st Floor Block # 3
Jain Society, Near Jain Temple
Sion (West), Mumbai 400 022
Maharashtra
Email: [email protected]
Noel Narayanan S
TC 1/1991 9(1)
Keezhchira, Doctors Lane
Kumarapuram
Thiruvananthapuram 695 001
Kerala
Nupur Ganguly
Assistant Professor of Pediatrics
Institute of Child Health, Kolkata
107 Garfa Pratapgarh
Kolkata 700 075
Email: [email protected]

Pankaj Hari
Additional Professor
Department of Pediatrics
All India Institute of Medical
Sciences, New Delhi 110 029
Email: [email protected]
Panna Choudhury
Consultant Pediatrician
Department of Pediatrics
Maulana Azad Medical College
and Lok Nayak Hospital
New Delhi 110 002, Delhi
Email: [email protected];
[email protected]
Paramesh H
Medical and Managing Director
Lakeside Medical Center and
Hospital
33/4 Meanee Avenue Road
Near Ulsoor Lake
Bengaluru 560 042, Karnataka
Email: [email protected]
Parang N Mehta
2/C Anjani Towers
Parle Point
Athwa Lines
Surat 395 007
Gujarat
Email: [email protected]

Omprakash S Shukla
33-B Shilalekh Bunglows
Opposite Nandanvan Society
Behind Railway Station, Alkapuri
Vadodara 390 007, Gujarat
Email: [email protected]

Parthasarathy A
Brindavan
166 Park Road
Western Extension
Anna Nagar
Chennai 600 101
Email: [email protected]

Pandian K
9B Medawakkam Road
Adambakkam
Chennai 600 088, Tamil Nadu
Email: [email protected]

Phadke KD
707 14th Cross
JP Nagar II Phase
Bengaluru 560 078
Karnataka

XVI

IAP Textbook of Pediatrics

Piyush Gupta
Professor of Pediatrics
University College of Medical Sciences
New Delhi
Editor-in-Chief, Indian Pediatrics
Residence
Block # R-6-A
Dilshad Garden
Near Telephone Exchange
Delhi 110 095
Email: [email protected]
Potdar RD
Laxmi Gruha
69 DV Pradhan Road
Dadar (East)
Mumbai 400 014
Email: [email protected]
Prahlad N
22/1 Poes Road, II Street
Teynampet
Chennai 600 018
Tamil Nadu
Email: [email protected]
Pratibha D Singhi
Chief Pediatric Neurology and
Neurodevelopment
Department of Pediatrics
Postgraduate Institute of
Medical Education and Research
Chandigarh 160 012
Email: [email protected]
Prisca Colaco
D-107 Gasper Enclave
St Johns Road, Bandra
Mumbai 400 050
Maharashtra
Purna A Kurkure
Professor-in-Charge
Pediatric Endocrinology Division
HOD, Departemnt of
Medical Oncology
Tata Memorial Hospital
Dr Ernest Borges Marg
Parel, Mumbai 400 012
Maharashtra

Residence
B 301 Greenfields
Lokhandwala Complex
Andheri West
Mumbai 400 053
Email: [email protected]
Purvish M Parikh
9 Neeta Building
Above Computer Point
Opposite Poddar Hospital
227 Annie Besant Road
Worli, Mumbai 400 025
Maharashtra
Raghupathy P
# 39 6th Cross 35th Main
KAS Officers Colony
BTM Layout IInd Stage
Bengaluru 560 068
Karnataka
Email: [email protected]
Rajeshwar Dayal
Opposite Kidwai Park
Rajamandi
Agra 282 002, Uttar Pradesh
Email: [email protected]
Rajniti Prasad
Senior Lecturer
Department of Pediatrics
Institute of Medical Sciences
Banaras Hindu University
Varanasi 221 005
Residence
7 FF Kabir Colony
Banaras Hindu University
Varanasi 221 005
Email: [email protected]
Rajput CS
C/o Dr Mrs MC Rajpur
Department of OBGYN
Wanless Hospital
Miraj 416 410, Maharashtra
Raju C Shah
Ankur Children Hospital
Behind City Gold Cinema
Ashram Road Navarangpura
Ahmedabad 380 009, Gujarat
Email: [email protected];
[email protected]

Rakesh Lodha
Assistant Professor of Pediatrics
All India Institute of
Medical Sciences
New Delhi 110 029
Residence
A-5 Type # 5
IARI, Pusa, New Delhi 110 012,
Email: [email protected],
[email protected]
Ramachandran P
Institute of Child Health and
Hospital for Children
Egmore, Chennai
Tamil Nadu
Ramakrishnan S
Shreyas
15/7 Vidya Marg
Old Fatehpura
Udaipur 313 004
Rajasthan
Ramaswamy Ganesh
Registrar in Pediatrics
Kanchi Kamakoti Childs TRUST
Hospital
12-A Nageswara Road
Nungambakkam
Chennai 600 033
Tamil Nadu
Residence
3-A Raju Street
West Mambalam
Chennai 600 033
Ramesh S
Consultant Pediatrician
BRS Hospital
28, Cathedral Garden Road
Chennai 600 034
Residence
New No 28 Old No 37
Madava Road
Mahalingapuram
Chennai 600 034, Tamil Nadu
Email: rameshsanthanakrishnan
@gmail.com

Contributors XVII
Rana KS
Senior Advisor Pediatrics and
Pediatric Neurology
Army Hospital R & R, Delhi Cantt
New Delhi 110 010
Email: [email protected]
Rao KS
Ragasudha
13/242 Matwada
Warangal 506 002
Andhra Pradesh
Rashmi Dalvi
C/o Dr BV Dalvi
A-10 Mutual CHS
Mogul Lane, Mahim
Mumbai 400 016, Maharashtra
Rashmi Kumar
HIG 111 Sector E
Aliganj, Lucknow 226 020
Uttar Pradesh
Email: [email protected];
[email protected]
Ravichander B
Senior Pediatric Consultant
Military Hospital
Bengaluru, Karnataka
Ravikumar T
New # 31 Old # 14
Jaganathapuram
3rd Street Chetpet
Chennai 600 031
Tamil Nadu
Email: [email protected]
Ravikumar VR
66 Cooperative Colony
KK Pudur
Coimbatore 641 038
Tamil Nadu
Email: [email protected]
Renu Sexena
Professor and Head
Department of Hematology
All India Institute of
Medical Sciences
New Delhi 110 029

Ritabrata Kundu
Professor of Pediatrics
Institute of Child Health
Kolkata, West Bengal
Residence
26A Sarat Chatterjee Road
Lake Town
Kolkata 700 089
Email: [email protected]
Riyaz A
Arakkal
Chalappuram
Kozhikode 673 002
Kerala
Email: [email protected]
Rohit C Agrawal
Director
Chandra-Jyoti Children Hospital
Mumbai, Maharashtra
Residence
603/4 Vindyachal
Neelkanth Valley
7th Road Raja Wadi
Ghatkopar (East)
Mumbai 400 077
Maharashtra
Email: [email protected]
Roshani N Taori
Research Officer
Department of Pediatrics
Seth GS Medical College
KEM Hospital, Parel
Mumbai 400 012, Maharashtra
Email: [email protected]
Roshni Bhagwat
Consultant Pediatric Oncologist
Mahakoshal Hospital
Jabalpur, Madhya Pradesh
Residence
Vatika Duplex
65 Napier Town
Jabalpur 482 001
Madhya Pradesh
Email: [email protected]

Sachdev HPS
E 6/12, Vasant Vihar
New Delhi 110 057
Email: [email protected]
Sajid Qureshi
Assistant Professor
Pediatric Surgical Oncology
Tata Memorial Hospital
Dr Ernest Borges Marg
Parel, Mumbai 400 012
Maharashtra
Residence
1/26 Merchant Building
3rd Sankli Street
Byculla, Mumbai 400 008
Maharashtra
Email: [email protected]
Sandeep B Bavdekar
A-2/9 Worli Seaside CHS
Kag Khan Road, Worli
Mumbai 400 018
Maharashtra
Email: [email protected]
Sankaranarayanan VS
16 Balaji Avenue
T Nagar, 1st Street
Chennai 600 017, Tamil Nadu
Email: [email protected]
Santosh K Bhargava
D 7 Gulmohar Park
New Delhi 110 049
Email: [email protected]
Saradha Suresh
Director and Superintendent
Institute of Child Health and
Hospital for Children
Egmore, Chennai 600 008
Tamil Nadu
Saroj Mehta
1159/15C, Chandigarh 160 015
Chandigarh
Email: [email protected]

XVIII

IAP Textbook of Pediatrics

Shah MD
51 2nd Floor Jashoda Niwas
Nehru Road
Vile Parle (East)
Mumbai 400 057
Maharashtra
Email: [email protected]
Shailesh Kanvinde
Consultant Pediatric Hematologist
and Oncologist
Deenanath Mangeshkar Hospital
Pune, Maharashtra
Residence
Prerana Society
Opposite New Abhinav Vidyalaya
37/2 Erandavane
Pune 411 038
Maharashtra
Email: [email protected];
[email protected]
Shanti Ghosh
5 Sri Aurobindo Marg
New Delhi 110 016, Delhi
Email: [email protected]
Shashi N Vani
10 Shamiana
61 Brahmin Mitra Mandal Society
Ahmedabad 380 006, Gujarat
Sheila Bhave
9 Solapur Road
Pune 411 001
Maharashtra
Email: [email protected]
Shivananda
Siddhi 608 3rd Stage
3rd Block, 7th Main
Basaveshwaranagar
Bengaluru 560 079
Karnataka
Email: [email protected]
Shivbalan SO
Consultant Pediatrician and
Pulmonologist
Sundaram Medical Foundation
Chennai, Tamil Nadu
Email: [email protected]

Shobha Banapurmath
390 8th Main
PJ Extension
Devangere 577 002
Karnataka
Email: [email protected]
Shreekant W Chorghade
Rajeev
Dharampeth
Nagpur 440 010, Maharashtra
Email: [email protected]
Shripad Banavali
Professor of Pediatric Oncology
Department of Medical Oncology
Tata Memorial Hospital
Dr Ernest Borges Marg
Parel, Mumbai 400 012
Maharashtra
Residence
# 11-A Jyoti Sadan,
Sheetla Devi Temple Road, Mahim
Mumbai 400 016
Email: [email protected]
Soumya Swaminathan
B-8 Sagarika
15-III Seaward Road
Valmiki Nagar
Chennai 600 041
Tamil Nadu
Email: [email protected]
Srikanta Basu
# 318 Aashirwad Enclave
104 IP Extension
Patparganj
New Delhi 110 092
Email: [email protected];
[email protected]
Srinivas S
Department of Gastroenterology
Royal Children's Hospital
Melbourne
Australia
Residence
14 Balaji Avenue
1st Street
Thiagarajanagar

Chennai 600 017

Tamil Nadu
Email: [email protected]
Srinivasan S
C II/4 Dhanvanthari Nagar
JIPMER, Puducherry 605 006
Puducherry
Email: [email protected]
Srivastava RN
487 Mandakini Enclave
Alaknanda
New Delhi 110 019
Email: [email protected]
Srivastava SP
S-104 Udai Giri Bhavan
Budh Marg Road, Patna 800 001
Bihar
Email: [email protected]
Subhash J Dalal
Consultant Pediatric Surgeon
Former Dean, Wadia Childrens
Hospital
Residence
3 Maheshwar Niketan
Peddar Road, Mumbai 400 026
Maharashtra
Subramanyam L
9-A Karneeswarar Koil Street
Santhome, Chennai 600 004
Tamil Nadu
Email: [email protected]
Suchitra Ranjit
G/A Ranga Nivas
40 Barnaby Road, Kilpauk
Chennai 600 010, Tamil Nadu
Email: [email protected]
Sudeshna Mitra
Department of Pediatrics
Postgraduate Institute of Medical
Education and Research
Chandigarh 160 012
Email: [email protected]

Contributors XIX
Sumathi B
Assistant Professor
Department of Pediatric
Gastroenterology
Institute of Child Health and
Hospital for Children
Egmore, Chennai 600 008
Residence
New No 6 (Old 24)
Kutchery Lane
Mylapore
Chennai 600 004
Tamil Nadu
Email: [email protected]
Sunanda K Reddy
Consultant Neurodevelopmental
Pediatrician
K-118 Ground Floor
Hauz Khas Enclave
New Delhi 110 016
Email: [email protected];
[email protected]
Sunil Karande
Flat # 24 Joothica, 5th Floor
22A Naushir Bharucha Road
Mumbai 400 007
Maharashtra
Email: [email protected]
Sunit C Singhi
Professor and Head
Department of Pediatrics
Advanced Pediatric Centre
PGIMER, Chandigarh 160 012
Email: [email protected];
[email protected]
Supriyo Ghose
Chief, Professor and Head of
Department of Ophthalmology
Rajendra Prasad Centre for
Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi 110 029

Surjit Singh
Department of Pediatrics
PGIMER, Chandigarh 160 012
Chandigarh
Email: [email protected];
[email protected]
Sushil Madan
804-2A Brindaban Apartments
Poonam Nagar, Andheri (East)
Mumbai 400 093, Maharashtra
Swati Kanakia
2/10 Shreeji Sadan
Vrindavan Society
Vrindavan Chowk
Sion, Chunabhatti
Mumbai 400 022
Maharashtra
Email: [email protected]
Swati Y Bhave
C II/47 Shahjahan Road
Opposite UPSC Office
New Delhi 110 003, Delhi
Email: [email protected];
[email protected]
Tanmay Amladi
Honorary Neonatologist
Nowrosjee Wadia Maternity
Hospital and NICU Parel, Mumbai
Residence
A/50/1368 MIG
Adarsh Nagar CHS Ltd
Prabhadevi
Mumbai 400 025
Maharashtra
Email: [email protected]
Tanu Singhal
Consultant Pediatrician
Kokilaben Dhirubhai Ambani
Hospital and Medical Research Institute
Four Bungalows, Andheri West
Mumbai 400 053, Maharashtra
Email: [email protected]

Tapan Kumar Ghosh

Scientific Coordinator
Institute of Child Health
Kolkata
Residence
13 Neogi Pukur Bye Lane
Kolkata 700 014
West Bengal
Email: [email protected],
[email protected]
Tewari AD
1459 Sector 3, Rohtak 124 001
Haryana
Email: [email protected]
Thangadorai C
18 Taylors Road, Kilpauk
Chennai 600 010
Tamil Nadu
Email: [email protected]
Thangavelu S
H-15, G-2 Sea Breeze Apartments
Thiruvalluvar Nagar
Thiruvanmiyur
Chennai 600 041, Tamil Nadu
Email: [email protected]
Thapa BR
Division of Pediatric
Gastroenterology
PGIMER
Chandigarh 160 012
Chandigarh
Email: [email protected];
[email protected]
Thirugnanasambandham C
8 I Block
2nd Main Road
Chennai 600 102
Tamil Nadu

XX

IAP Textbook of Pediatrics

Uday B Nadkarni
2 Vaibhav, Plot # 12-13
Linking Road Extension
Santacruz (West)
Mumbai 400 054
Maharashtra

Vasanthi T
Old # 4/123 New # 4/693
7th Main Road, Swaminatha Nagar
Kottivakkam
Chennai 600 041
Tamil Nadu
Email: [email protected]

Vijay Agarwal
Cottage # 15
Oberai Apartments
2 Sham Nath Marg
Delhi 110 054
Email: [email protected]

Upadhyay SK
402 Bhimarathi Building
Road # 3 Daulal Nagar
Borivali (East)
Mumbai 400 066
Maharashtra

Veena Kalra
Senior Consultant Pediatrics
(Pediatric Neurology)
Indraprastha Apollo Hospitals
Sarita Vihar, Delhi Mathura Road
New Delhi 110 076
Residence
101 Jorbagh
New Delhi 110 003, Delhi
Email: [email protected]

Vijay N Yewle
Yewale Hospital
Plot 6B Sector 9
Vashi 400 703
Navi Mumbai
Maharashtra
Email: [email protected];
[email protected]

Utpal Kant Singh

Professor and Head
Department of Pediatrics
Nalanda Medical College
Patna, Bihar
Residence
8 Rajendra Nagar
Patna 800 016, Bihar
Email: [email protected]
Vaman V Khadilkar
B-3 Shashi Kiran Apartment
Ashok Path
Off Law College Road
Erandwane
Pune 411 004, Maharashtra
Email: [email protected];
[email protected]
Varshney MK
Senior Research Associate
Department of Orthopedics
All India Institute of Medical Sciences
New Delhi 110 029
Residence
521 Masjid Moth Doctors Hostel
Masjid Moth
New Delhi 110 049
Email: [email protected]

Vibha Jain
Consultant
Department of Pediatrics
Himalayan Institute of
Medical Sciences
Jolly Grant, Dehradun 248 140
Uttarakhand
Residence
77 SBM Complex
Haridwar Road
Rishikesh
Vibha Mangal
Consultant
Department of Pediatrics
Himalayan Institute of
Medical Sciences
Swami Rama Nagar
Dehradun 248 140
Uttarakhand
Vibhu Kwatra
Vibhu Nursing Home
11/137 Malviya Nagar
New Delhi

Vijayakumar M
Flat # 4 Muktha Vandan
Old # 4 New # 7
Ramanathan Street
Kilpauk
Chennai 600 010
Email: [email protected]
Vijayalakshmi Bhatia
Professor
Department of Endocrinology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Post Box # 375
Lucknow 226 001
Uttar Pradesh
Email: [email protected]
Vijayasekaran D
# 43rd Cross Street
Dr Subbaraya Nagar
Kodambakkam
Chennai 600 024
Tamil Nadu
Email: [email protected]

Contributors XXI
Vimlesh Seth
N-14/D DDA Flats (SFS)
Mandir Marg, Saket
New Delhi 110 017, Delhi
Email: [email protected]
Vinod K Paul
Professor and Head
Department of Pediatrics
All India Institute of Medical Sciences
Ansari Nagar
New Delhi 110 029, Delhi
Email: [email protected];
[email protected]
Vipin M Vashishtha
Consultant Pediatrician and
Neonatologist, Mangla Hospital
Shakti Chowk, Station Road
Bijnor 246 701, Uttar Pradesh
Email: [email protected],
[email protected]
Vrajesh P Udani
69 Al Jebreya Court
Marine Drive, Mumbai 400 020
Maharashtra
Email: [email protected];
[email protected]

Walia BNS
1004 Sector 11-C
Chandigarh 160 011
Email: [email protected]
Wilson CG
House # 117 Sector A
A WHO Colony
Gautam Enclave
Secunderabad 500 009
Andhra Pradesh
Email: [email protected]
Yogesh C Govil
4006/1/2, A-2 Balda Colony
New Hyderabad
Lucknow 226 007
Uttar Pradesh
Email: [email protected]
Yogesh Jain
Jan Swasthya Sahyog
I-4 Parijat Colony
Nehru Nagar
Bilaspur 495 001
Chhattisgarh
Email: [email protected]

Yuvaraj Chandra Mathur

4-1-1233 Boggul Kunta
Subodaya
Hyderabad 500 001
Andhra Pradesh
Email: [email protected]
Zeenat Currimbhoy
Division of Pediatric
Hemato-Oncology
Department of Pediatrics
LTMG Hospital and
LTM Medical College
Sion, Mumbai 400 022
Maharashtra
Email: [email protected]
Zulfikar Ahamed M
SAJAN, TC 1072/4
Pazhaya Road MCPO
Thiruvananthapuram 695 011
Kerala
Email::[email protected];
zulfikarahamedm@sancharnet

Foreword
Child health needs of developing countries are altogether different. Indian Academy of Pediatrics is dedicated for
total child welfare from zero to eighteen years of age. With this aim, the first edition was published in 1999 and in
ten years it has been so popular, not only in India but in SAARC and many developing countries. It speaks of its
receptivity, utility, affectivity and relevance. And now with much enthusiasm and pleasure, the fourth edition is in
your hands.
I sincerely appreciate Dr A Parthasarathys dedication and commitment to the children and in the professional
front in our country. His untiring efforts will serve as an inspiration for young pediatricians to emulate and encourage
them to contribute to ailing society along their professional path with sincere services.
It is certainly a matter of pride to note that many senior pediatricians have been taking time off their innumerable
social commitments to pool valuable knowledge in the form of this book. I admire all the editors and contributors
for this rich compilation.
The contents of the book have been chosen very carefully for developing as well as developed countries and
have broadly covered the relevant and vital issues of Comprehensive Child Health Care. Considering the caliber
and expertise of contributors and authors, I am convinced that the book will be a treasure of knowledge to be
cherished by the pediatricians across the world.
RK Agarwal
National President, 2008
Indian Academy of Pediatrics

Foreword
Specialty of Pediatrics covers more than 50 percent of the population. Infant and childhood morbidity continue to be
very high and adolescent health problems are still not adequately addressed by medical profession. Thus, it is
imperative that budding doctors need to have sound training to look after the children from birth to 18 years.
Pediatrics is a part of undergraduate curriculum and there is tremendous demand for a textbook on pediatrics. For
credibility it is also necessary that the book is evidence based. IAP Textbook of Pediatrics fulfills an important void
in this direction and has become immensely popular with all its editions. The book has been well received in many
developing countries having similar health scenario.
Contributors of this book are renowned experts in their respective fields. An invariable problem with multiauthored texts is the diversity of presentations adopted by a multitude of contributors. Dr A Parthasarathy, Editorin-Chief of the book since inception and an accomplished academician with tremendous zeal, managed this issue by
carefully crafting a common editorial style. In this venture he has been aptly assisted by Dr PSN Menon and
Dr Piyush Gupta, along with many highly reputed chapter editors. Keeping with time, the text of the book has been
aptly modified and all the chapters have been thoroughly revised.
The book is designed to be relevant to the need of the developing countries. Emphasis has been on common
prevalent conditions though allied subjects seen in children have also received due attention. Section on Community
Pediatrics deserves special mention as most textbooks with western approach hardly provide any information in
this respect. The book is voluminous which is inherent in a textbook trying to cover all aspects related to pediatric
care.
Apart from fulfilling the main function of an excellent undergraduate textbook, this edition would be invaluable
for residents and medical practitioners interested to know in detail various childhood conditions. Even postgraduate
students will find much useful information. The book certainly will continue to remain as a very prestigious
publication of Indian Academy of Pediatrics and serve the nation by helping doctors engaged in the care of children
needing latest updates.
Panna Choudhury
Consultant Pediatrician
Lok Nayak Hospital
New Delhi 110 002 and
National President
Indian Academy of Pediatrics 2009

Preface to the Fourth Edition

The last few years have witnessed a rapid progress in medicine and technological advances in biological sciences.
The specialty of Pediatrics has perceived further advances in preventive and therapeutic care. These have provided
impetus to revise knowledge, harvest new information and thus continue the process of learning. There was a felt
need for publication of an updated fourth edition of this book after a gap of three years. This was also prompted by
the enthusiastic response to the previous editions from practicing pediatricians, postgraduates, undergraduates as
well as faculty of Departments of Pediatrics throughout the country.
It has been our endeavor to present this subject in a simplified, practical manner to provide adequate clinical
guidance to pediatricians so that children derive the benefits of early diagnosis and optimal treatment. The basic
outline of the book is retained. We have tried our best to oversee that the art and science of clinical pediatrics
maintains its central position without being overshadowed by newer technical advances.
This fourth edition of the IAP Textbook represents a substantial revision and reorganization of the text based on
a complete review of the field of Pediatrics. It has 36 chapters and is being published in two volumes for the first
time. The first volume consists of 16 chapters with 195 subchapters contributed by 171 authors and the second
volume contains 20 chapters with 95 subchapters by 89 authors. The first volume features 28 new authors while the
second volume has 14 new authors representing the continuum of the best available talent, both experienced and
young with vast experience and expertise. Almost all the chapters have been thoroughly revised and updated in a
lucid and readable style.
Several new chapters have been added keeping in mind the changing concepts of pediatric care in the global
scenario. Some of these include child and adolescent school health education, vaccine storage and handling adverse
effects following immunization, parent counseling, practical approach to fever in children, pneumococcal infection
and its prevention, chikungunya fever, hemoptysis, gastroesophageal reflux, allergen-specific immunotherapy,
antiphospholipid syndrome, vasculitis, intravenous immunoglobulin, polycystic ovarian syndrome, etc. The chapters
on research methodology and computers serve a long felt need.
In addition, the IAP Infectious Diseases Chapter Protocols on selected infectious diseases viz. malaria, enteric
fever, pyogenic meningitis and rabies have been incorporated in the Miscellaneous Topics. This edition also provides
the most recent IAP recommendations on immunization of children and adolescents. The current IAP and WHO
growth charts have been appended with details on the techniques of measurement and interpretation. Unfortunately
many children, especially from the rural and remote areas have not yet benefited from the significant advances in
the prevention and care of many health problems. In this context the two chapters viz. National Rural Health Mission
and Pediatric Priorities in the 21st Century are rewritten. The chapter on Common Procedures has been updated.
The Academy would like to place on record its appreciation to all the authors for their contributions to the fourth
edition. It also gratefully acknowledges the efforts and time spent by Senior Editors and Chapter Editors who have
devoted great deal of their time reviewing and editing the manuscripts. The support from the office-bearers and
staff of the IAP Central Office Secretariat at all stages is appreciatively accredited. The book would not have seen the
light of the day but for the support and excellent cooperation of M/s Jaypee Brothers Medical Publishers (P) Ltd,
New Delhi.
It is our earnest hope that this new edition of the IAP Textbook will help in early diagnosis and efficient
management leading to optimal outcome and improving the quality of patient care.
A Parthasarathy
PSN Menon
Piyush Gupta
MKC Nair

Preface to the First Edition

Pediatrics has grown and developed with significant milestones in preventive and therapeutic care over the past
few decades. The WHO and UNICEF in their Primary Health Care (PHC) approach, have given due importance for
effective child survival programs. So much so the medical students need to be well oriented towards these approaches
in Pediatrics as the future middle level managers in Primary Health Care.
Several luminaries in the Indian pediatric scenario, have contributed their might in bringing out books for the
undergraduate medical students. However, the rapid advances made in the various pediatric subspecialties have
necessitated the updating of these books from time to time. Nevertheless, the need for a full fledged textbook was
felt for long. The Indian Academy of Pediatrics thought it fit, to shoulder the responsibility of bringing out such a
need based Textbook in Pediatrics for medical students. Our erudite and enthusiastic editors and contributors
made it possible at a record time. The Academy owes its gratitude to all these experts for their worthy contribution.
The book has been divided into several sections. A few chapters included in this book are entirely newer concepts
which are not usually found in the conventional pediatric textbooks. It has also worthy annexures to the main
contents. However, editing the text to suit the needs of medical students was a Himalayan task. The idea is to equip
the medical students with adequate knowledge in Pediatrics in order to make them confident to shoulder the
responsibilities concerned with preventive and curative Pediatrics. Thus, it is hoped that the practitioners of Pediatric
Medicine will benefit from this book.
We are confident that this book will serve the needs of medical students especially at a time when the Medical
Council of India has made Pediatrics as a major examination subject. Thus, the publication of the book is not only
timely but also out of necessity.
The Academy would like to place on record its appreciation to the senior editors, chapter editors, contributors,
and staff members of IAP Central Secretariat for help rendered in the creation of this book and M/s Jaypee Brothers
Medical Publishers (P) Ltd., New Delhi, for their excellent cooperation in bringing out the First Edition at record
time.
A Parthasarathy
PSN Menon
MKC Nair

Acknowledgements
We are indebted to the President and members of the Executive Board 1997 of the Indian Academy of Pediatrics
(IAP) for the initiation and completion of the project of bringing out the first ever Academys textbook for medical
students and practitioners. We are also thankful to the successive Presidents and members of the Executive Boards
1998-2008 for their encouragement in sustaining the project towards the publication of the Fourth Edition.
Our grateful thanks go to the various contributors and senior editors, past and present teachers of Pediatrics who
have made this Himalayan task a reality by their precise and updated text. We are indebted to the faculty and
residents of the All India Institute of Medical Sciences, New Delhi for shaping the contents of the First Edition which
has made the production of the subsequent editions an easy task and to Ms Manju, Ms Chitra and Ms Suman for
their assistance in typing and drafting the text of the book for the first edition.
The secretarial and organizational skills of Mr Joseph A Gonzalves and his supportive staff of IAP Central Office,
Mumbai, so ably and meticulously guided by Dr Rohit Agrawal, Secretary General and Dr Tanmay Amladi, Treasurer
are also gratefully acknowledged. The coordination efforts of Mrs Lokanayaki Ethirajan, Mrs Nirmala Parthasarathy,
Dr (Mrs) Pratibha Janardhanan, Mrs Kavitha Balaji, Mr A Sriramulu and Mr Louis Francis are acknowledged with
thanks.
Mr R Janardhanan, Mr P Balaji, Ms Shruthi Pavana, Ms Swathi Pavana, Ms Kavya Balaji and Ms Mahia Balaji at
Chennai need special mention for their untiring assistance in correspondence and formatting of the book with
updated contents.
Our grateful thanks are due to Mr Shaji Jacob Ninan and Dr Nazeer Ahamed at Kuwait for the assistance rendered
to the senior editor in editing, scrutinizing and proofreading of the individual chapter files.
Our sincere and grateful thanks go to the family of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,
especially Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Vij (Director-Pharma), Mr Tarun Duneja
(Director-Publishing), Mr KK Raman (Production Manager), Ms Samina Khan (PA to the Director-Publishing),
Mr Ashutosh Srivastava (Assistant Editor), Ms Yashu Kapoor and Ms Kamlesh Bisht (DTP Operators) and
Ms Sonia Mehta (Graphic Designer) for their untiring coordination efforts in the production of the Fourth Edition.
We also place on record our sincere appreciation of the help rendered by the local branch managers of the Jaypee
Brothers Mr Mukherjee, (Chennai), Mr Uday Honnemadi (Mumbai), Mr Jayanandan (Author Co-ordinator,
Chennai), Mr Damodharan (Field Executive, Chennai) and the headquarters staff at New Delhi for the help
rendered to the Editor-in-Chief and Academic/Senior Editors.
All attempts have been made to acknowledge the sources of information and illustrations. Inadvertent omission,
if any, is regretted.
A Parthasarathy
PSN Menon
Piyush Gupta
MKC Nair

Contents
Volume 1
1. PEDIATRIC CARE IN DEVELOPING COUNTRIES
Chapter Editor: Piyush Gupta
1.1 Importance of Pediatrics ............................................................................................................................ 2
RD Potdar
1.2 Attaining Proficiency in Pediatrics .......................................................................................................... 3
BNS Walia
1.3 Pediatric Care in Developing Countries ................................................................................................. 5
BNS Walia
1.4 Primary Health Care ................................................................................................................................... 7
Yuvraj Chandra Mathur, Nitin Chandra Mathur
1.5 Primary Neonatal Care .............................................................................................................................. 9
Santosh K Bhargava
1.6 Management of Primary Health Center ............................................................................................... 12
Piyush Gupta
1.7 Training of Medical Graduate as Middle Level Manager ................................................................ 16
C Thirugnanasambandham, T Arunmozhi

2. HISTORY ELICITATION AND PHYSICAL EXAMINATION

Chapter Editors: PSN Menon, Piyush Gupta
2.1 History Elicitation ..................................................................................................................................... 24
T Ravikumar, C Thangadorai
2.2 Physical Examination and Clinical Skill Development .................................................................... 30
C Thangadorai, T Ravikumar
2.3 Parent Counseling .................................................................................................................................... 40
Parang N Mehta

3. NEWBORN CARE
Chapter Editor: Ashok K Deorari
3.1 Neonatal Nomenclature and Definitions ............................................................................................. 46
Meharban Singh, Vinod K Paul
3.2 Resuscitation of an Asphyxiated Newborn Baby ............................................................................... 50
Meharban Singh, Ashok K Deorari
3.3 Care of a Normal Newborn Baby .......................................................................................................... 56
Meharban Singh, Ashok K Deorari

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IAP Textbook of Pediatrics

3.4 Common Developmental and Physiological Problems in Newborn Babies ................................. 61

Meharban Singh, Vinod K Paul
3.5 Management of Low Birth Weight Babies ........................................................................................... 65
Vinod K Paul, Ashok K Deorari, Meharban Singh
3.6 Common Diseases of Newborn Babies ................................................................................................ 71
Meharban Singh, Vinod K Paul, Ashok K Deorari

4. GROWTH AND DEVELOPMENT

Chapter Editor: KN Agarwal
4.1 Growth and Development: Basic Concepts ......................................................................................... 80
AB Desai, Dilip Mukherjee
4.2 GrowthBirth to Puberty ....................................................................................................................... 83
KN Agarwal, DK Agarwal, SK Upadhyay
4.3 Physical Growth and Sexual Development in Adolescence ............................................................. 96
KN Agarwal, DK Agarwal, SK Upadhyay
4.4 Development ........................................................................................................................................... 105
KN Agarwal, DK Agarwal, SK Upadhyay
4.5 Failure to Thrive ...................................................................................................................................... 111
Madhulika Kabra, PSN Menon

5. INFANT FEEDING
Chapter Editor: RK Anand
5.1 Infant and Young Child Feeding ......................................................................................................... 116
RK Anand, SP Srivastava
5.2 Breastfeeding and Weaning .................................................................................................................. 122
RK Anand, SP Srivastava, Arun Gupta, JP Dadhich

6. NUTRITION
Chapter Editor: Meenakshi N Mehta
6.1 Protein Energy Malnutrition ............................................................................................................... 136
Meenakshi N Mehta
6.2 Water Soluble Vitamins: B Complex Vitamins ................................................................................ 163
Shashi N Vani
6.3 Fat Soluble Vitamins ............................................................................................................................. 166
Panna Choudhury
6.4 Trace Elements ....................................................................................................................................... 171
B Bhandari
6.5 Child and Adolescent School Health Education .............................................................................. 176
Sushil Madan

Contents XXXV

7. COMMUNITY PEDIATRICS
Chapter Editor: Piyush Gupta
7.1 Community Pediatrics .......................................................................................................................... 188
Shashi N Vani
7.2 National Health Programs .................................................................................................................... 190
Shashi N Vani, Piyush Gupta
7.2.1 National Rural Health Mission (NRHM) 2005-2012 ........................................................... 191
Piyush Gupta
7.2.2 Maternal and Child Health (MCH) Programs ...................................................................... 193
Shashi N Vani
7.2.3 Integrated Child Development Services (ICDS) Program ................................................. 194
BNS Walia
7.2.4 Child Survival and Safe Motherhood (CSSM) Program .................................................... 196
BNS Walia
7.2.5 Reproductive and Child Health (RCH) Program ................................................................. 197
BNS Walia, Shashi N Vani
7.2.6 Integrated Management of Neonatal and Childhood Illness (IMNCI) Strategy .......... 200
BNS Walia
7.2.7 National Programs on Immunization .................................................................................... 200
A Parthasarathy, Shashi N Vani, BNS Walia
7.2.7.1 Universal Immunization Program (UIP) .................................................................. 200
KM Ganessan
7.2.8 Acute Respiratory Infections (ARI) Control Program ........................................................ 202
Keya R Lahiri, BNS Walia, Shashi N Vani
7.2.9 Control of Diarrheal Disease (CDD) Program ..................................................................... 203
BNS Walia, Shashi N Vani
7.2.10 National Leprosy Eradication Program ................................................................................. 204
BNS Walia
7.2.11 National Vector Borne Disease Control Program (NVBDCP) .......................................... 206
Piyush Gupta
7.2.11.1 National Malaria Control Program ................................................................... 206
BNS Walia
7.2.11.2 National Filaria Control Program ...................................................................... 207
BNS Walia
7.2.12 National AIDS and STD Control Program ........................................................................... 207
BNS Walia
7.2.13 Nutrition Programs ................................................................................................................... 208
Shashi N Vani
7.2.14 Mid-day Meal Program ............................................................................................................ 209
HPS Sachdev
7.2.15 Anemia Control Program ......................................................................................................... 209
Shashi N Vani
7.2.16 Control of Vitamin A Deficiency ........................................................................................... 210
BNS Walia
7.2.17 National Iodine Deficiency Disorders Control Program ................................................... 210
N Kochupillai

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7.3
7.4
7.5
7.6
7.7
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IAP Textbook of Pediatrics

7.2.18 National School Health Program .......................................................................................... 211
BNS Walia
7.2.19 National Cancer Control Program ......................................................................................... 211
BNS Walia
7.2.20 National Mental Health Program (NMHP) ......................................................................... 211
BNS Walia
7.2.21 National Program for Control of Blindness ........................................................................ 211
BNS Walia
Community Newborn Care .................................................................................................................. 212
Shashi N Vani
Under Five Clinics ................................................................................................................................. 215
Ajit Kumar
The Girl Child ........................................................................................................................................ 218
Shanti Ghosh
Customs and Beliefs in Child Rearing .............................................................................................. 220
Anil Mokashi
International Agencies and Child Health ......................................................................................... 225
Shashi N Vani
Adoption and Care of Orphans ........................................................................................................... 226
RD Potdar

8. CHILD ABUSE, NEGLECT AND CHILD LABOR

Chapter Editors: Meenakshi N Mehta, SR Banerjee
8.1 Child Abuse and Neglect ...................................................................................................................... 230
Meenakshi N Mehta
8.2 Child Labor .............................................................................................................................................. 244
Meenakshi N Mehta, SR Banerjee

9. IMMUNIZATION AND INFECTIOUS DISEASES

Chapter Editors: A Parthasarathy, Tapan Kumar Ghosh
9.1 The Principles and Practice of Immunization ................................................................................... 258
T Jacob John
9.2 Vaccines and Vaccine Preventable Diseases: Today and Tomorrow ............................................ 262
AB Desai
9.3 Newer Vaccines ....................................................................................................................................... 265
AK Dutta, Anju Aggarwal
9.4 Vaccine Storage and Handling ............................................................................................................. 271
RK Agarwal, Digant D Shastri
9.5 Management of Adverse Effects Following Immunization (AEFI) ............................................... 277
M Indra Shekhar Rao, Tanmay Amladi
9.6 Approach to Management of Fever in Newborns, Children and Adolescents
in Office Practice ..................................................................................................................................... 285
Digant D Shastri

Contents XXXVII
9.7 Fever and Fever of Unknown Origin .................................................................................................. 295
PP Maiya
9.8 An Approach to a Child with Fever and Skin Rash ......................................................................... 302
Jayakar Thomas
9.9 Tuberculosis in Children....................................................................................................................... 315
Vimlesh Seth
9.10 Abdominal Tuberculosis ....................................................................................................................... 332
Saroj Mehta, Vimlesh Seth
9.11 Neurotuberculosis .................................................................................................................................. 336
Vimlesh Seth
9.11.1 Revised National Tuberculosis Control Program (RNTCP) including
Directly Observed Treatment .................................................................................................. 342
Vimlesh Seth
9.12 Poliomyelitis ............................................................................................................................................ 350
Ashok K Gupta
9.12.1 Differential Diagnosis of Acute Flaccid Paralysis ............................................................... 354
AD Tewari
9.12.2 National Immunization Days (NIDs) as a Vital Component of Polio Eradication
Strategy ......................................................................................................................................... 359
Vipin M Vashishtha, Naveen Thacker
9.13 Diphtheria ................................................................................................................................................ 362
AP Dubey, Jaydeep Choudhury
9.14 Pertussis (Whooping Cough) ................................................................................................................ 364
YK Amdekar
9.15 Tetanus ..................................................................................................................................................... 366
AP Dubey, Jaydeep Choudhury
9.16 Measles ..................................................................................................................................................... 368
AP Dubey, Jaydeep Choudhury
9.17 Mumps: Epidemic Parotitis ................................................................................................................... 370
Ashok Gupta
9.18 Rubella ...................................................................................................................................................... 372
AP Dubey, Jaydeep Choudhury
9.19 Staphylococcal Infections ...................................................................................................................... 374
AK Dutta, Anju Aggarwal
9.20 Pneumococcal Disease and its Prevention ......................................................................................... 376
Rohit C Agrawal
9.21 Hemophilus Influenzae b Disease ...................................................................................................... 383
RK Agarwal, Anju Aggarwal
9.22 Typhoid Fever ......................................................................................................................................... 383
YK Amdekar
9.23 Leprosy ..................................................................................................................................................... 387
Rajeshwar Dayal
9.24 Leptospirosis in Children ...................................................................................................................... 392
S Ramesh
9.25 Chickenpox (Varicella) .......................................................................................................................... 394
AP Dubey, Jaydeep Choudhury

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IAP Textbook of Pediatrics

9.26 Dengue Illnesses ..................................................................................................................................... 396

Ashok S Kapse
9.27 Infectious Mononucleosis ..................................................................................................................... 404
S Ramesh
9.28 Respiratory Syncytial Virus Infection ................................................................................................ 405
A Balachandran, SO Shivbalan
9.29 Rotavirus Disease ................................................................................................................................... 408
Raju C Shah
9.30 Rabies ........................................................................................................................................................ 409
Tapan Kumar Ghosh, A Parthasarathy
9.31 Pediatric HIV Disease ............................................................................................................................ 414
Meena Malkani
9.32 Chikungunya Fever ................................................................................................................................ 419
Utpal Kant Singh, Rajniti Prasad
9.33 Malaria in Children ................................................................................................................................ 423
Ashok S Kapse
9.34 Kala-azar (Visceral Leishmaniasis) ..................................................................................................... 440
Yogesh Jain, Rakesh Lodha

10. DISEASES OF CENTRAL NERVOUS SYSTEM

Chapter Editors: Veena Kalra, PSN Menon
10.1 Anatomical Localization of Neurological Problems ....................................................................... 444
CS Rajput, DP Karmarker
10.2 Normal Development and Malformations of Central Nervous System ..................................... 448
Veena Kalra, Rashmi Kumar
10.3 Degenerative Disorders of the Central Nervous System ............................................................... 453
Veena Kalra
10.4 Seizure Disorders in Children ............................................................................................................ 455
Veena Kalra
10.5 Infections of the Central Nervous System ........................................................................................ 462
Veena Kalra
10.6 Coma in Children .................................................................................................................................. 470
CR Banapurmath, Shobha Banapurmath, G Guruprasad
10.7 Brain Tumors in Children .................................................................................................................... 477
KS Rana
10.8 Raised Intracranial Pressure ................................................................................................................ 486
AD Tewari, Kundan Kumar Mittal
10.9 Benign Intracranial Hypertension ...................................................................................................... 489
AD Tewari, Kundan Kumar Mittal
10.10 Motor Weakness in Infancy and ChildhoodClinical Approach ............................................... 491
Vrajesh Udani
10.11 Floppy Infant Syndrome ...................................................................................................................... 495
R Anandam, D Kalpana
10.12 Muscular Disorders in Children ......................................................................................................... 499
K Pandian

Contents XXXIX

11. DISEASES OF CARDIOVASCULAR SYSTEM

Chapter Editors: Anita Khalil, Srikanta Basu
11.1 Congenital Heart Disease: General Aspects ..................................................................................... 504
NC Joshi
11.2 Common Congenital Heart Diseases in Children ........................................................................... 509
Anita Khalil, M Zulfikar Ahamed
11.3 Medical Management of Congenital Heart Diseases ..................................................................... 518
Anita Khalil, Bharat Dalvi
11.4 Surgery for Congenital Heart Diseases ............................................................................................. 521
KS Dagar, KS Iyer, Srikanta Basu
11.5 Rheumatic Fever and Rheumatic Heart Disease .............................................................................. 526
Anita Khalil
11.6 Congestive Heart Failure in Children ................................................................................................ 534
Anita Khalil
11.7 Systemic Arterial Hypertension in Children .................................................................................... 538
Srikanta Basu, S Srinivasan
11.8 Pericardial Diseases and Disorders .................................................................................................... 548
S Srinivasan, Srikanta Basu
11.9 Cardiac Arrhythmias in Children ....................................................................................................... 551
S Srinivasan, Srikanta Basu

12. DISEASES OF RESPIRATORY SYSTEM

Chapter Editor: A Balachandran
12.1 Examination of the Respiratory System ............................................................................................ 558
YK Amdekar
12.2 Diagnostic Procedures and Investigations in Respiratory Diseases ............................................ 560
Archana S Kher, Soumya Swaminathan, Milind S Tullu
12.3 Flexible Fiberoptic Bronchoscopy (FFBS) ......................................................................................... 564
D Vijayasekaran
12.4 Respiratory Distress .............................................................................................................................. 567
MD Shah
12.5 Upper Respiratory Tract Infection ..................................................................................................... 573
SK Kabra
12.6 Infections of Larynx, Trachea and Bronchi ....................................................................................... 576
Keya R Lahiri, Roshani N Taori
12.7 Pneumonia in Children ........................................................................................................................ 578
A Balachandran, SO Shivbalan
12.8 Acute Bronchiolitis ................................................................................................................................ 583
Uday B Nadkarni
12.9 Empyema ................................................................................................................................................. 586
A Balachandran, Swati Y Bhave, S Thangavelu
12.10 Bronchiectasis ......................................................................................................................................... 588
A Balachandran, Swati Y Bhave, NC Gowrishankar

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IAP Textbook of Pediatrics

12.11 Lung Abscess .......................................................................................................................................... 589
A Balachandran, Swati Y Bhave, S Thangavelu
12.12 Hemoptysis ............................................................................................................................................. 591
Vibha Mangal, Neeraj Jain, Vibhu Kwatra
12.13 Bronchial Asthma .................................................................................................................................. 593
H Paramesh, L Subramanyam, SO Shivbalan

13. DISEASES OF GASTROINTESTINAL SYSTEM AND LIVER

Chapter Editor: VS Sankaranarayanan
13.1 Diarrheal Diseases ................................................................................................................................ 602
Ashok K Patwari
13.2 Persistent and Chronic Diarrhea in Children ................................................................................... 609
Gadadhar Sarangi, Jnanindra Nath Behera
13.3 Parenteral Nutrition in Children ........................................................................................................ 613
Anand N Pandit, Ashish R Bavdekar
13.4 Parasitic Bowel Diseases ...................................................................................................................... 616
BD Gupta
13.5 Vomiting in Infants and Children ...................................................................................................... 620
S Nagabhushana
13.6 Gastroesophageal Reflux in Infants and Children .......................................................................... 622
Neeraj Jain, Vibha Jain, Deepak Seth
13.7 Gastrointestinal Bleeding in Infants and Children ......................................................................... 624
Saroj Mehta, RC Mathur
13.8 Constipation ........................................................................................................................................... 627
VR Ravikumar
13.9 Abdominal Pain ..................................................................................................................................... 629
S Srinivas
13.9.1 Acute Abdominal Pain in Children ...................................................................................... 629
13.9.2 Chronic Abdominal Pain in Children .................................................................................. 632
13.10 Helicobacter Pylori Infection in Children ........................................................................................ 637
Neeraj K Jain, Vibha Mangal
13.11 Cystic Fibrosis ........................................................................................................................................ 639
Sushil K Kabra, Madhulika Kabra
13.12 Juvenile Tropical Pancreatitis ............................................................................................................. 644
A Riyaz
13.13 Liver and Biliary System ...................................................................................................................... 646
B Bhaskar Raju, B Sumathi
13.14 Hepatosplenomegaly: A Practical Diagnostic Approach ............................................................... 650
Sheila Bhave, Ashish Bavdekar
13.15 Differential Diagnosis of Jaundice in Infancy ................................................................................. 653
MK Jain, Sunil Karande
13.16 Viral Hepatitis ........................................................................................................................................ 655
Malathi Sathiyasekaran, Ramaswamy Ganesh

Contents XLI
13.17 Chronic Hepatitis in Children ............................................................................................................. 667
BR Thapa
13.18 Chronic Liver Disorders in Children ................................................................................................. 672
VS Sankaranarayanan, S Srinivas
13.19 Cirrhosis of Liver ................................................................................................................................... 675
VS Sankaranarayanan, S Srinivas
13.20 Neonatal Cholestasis Syndrome ......................................................................................................... 682
BR Thapa
13.21 Fulminant Hepatic Failure ................................................................................................................... 692
Rajiv Chandra Mathur
13.22 Ascites ...................................................................................................................................................... 695
Balvir S Tomar, Anurag Tomar

14. DISEASES OF KIDNEY AND URINARY TRACT

Chapter Editors: Arvind Bagga, RN Srivastava
14.1 Renal Anatomy and Physiology ......................................................................................................... 714
Arvind Bagga
14.2 Diagnostic Evaluation ........................................................................................................................... 715
RN Srivastava, Aditi Sinha
14.3 Imaging of the Urinary Tract ............................................................................................................... 719
Arvind Bagga, Aditi Sinha
14.4 Developmental Anomalies .................................................................................................................. 722
M Vijayakumar
14.5 Acute Proliferative Glomerulonephritis ........................................................................................... 724
BR Nammalwar, T Vasanthi, M Vijayakumar
14.6 Renal Vasculitis ..................................................................................................................................... 729
BR Nammalwar, N Prahlad
14.7 Acute Renal Failure ............................................................................................................................... 737
Arvind Bagga, Aditi Sinha
14.8 Nephrotic Syndrome ............................................................................................................................. 743
RN Srivastava, Arvind Bagga
14.9 Urinary Tract Infection, Vesicoureteric Reflux and Reflux Nephropathy .................................. 750
M Vijayakumar, RN Srivastava
14.10 Obstructive Uropathy ........................................................................................................................... 754
Kumud P Mehta
14.11 Disorders of Micturition ...................................................................................................................... 755
Kumud P Mehta
14.12 Chronic Kidney Disease ....................................................................................................................... 757
KD Phadke, Pankaj Hari
14.13 Hypertension .......................................................................................................................................... 761
Kumud P Mehta
14.14 Renal Tubular Disorders ...................................................................................................................... 763
Aditi Sinha, Arvind Bagga

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IAP Textbook of Pediatrics

15. PEDIATRIC HEMATOLOGY

Chapter Editor: MR Lokeshwar
15.1 Anemia in Children ............................................................................................................................... 768
MR Lokeshwar, VP Choudhry
15.2 The Value of a Complete Blood Count in Children ........................................................................ 771
Zeenat Currimbhoy
15.3 Anemia in the Newborn ....................................................................................................................... 775
Jayashree A Mondkar, Mamta Manglani, Armida Fernandez
15.4 Nutritional Anemias in Infancy and Childhood ............................................................................. 780
Niranjan Shendurnikar, Omprakash Shukla, Sushil Madan
15.5 Nutritional Anemias in Adolescence ................................................................................................. 785
Sushil Madan
15.6 Thalassemia ............................................................................................................................................ 794
MR Lokeshwar, Nitin Shah, Swati Kanakia, Mamta Manglani
15.7 Sickle Cell Disease ................................................................................................................................ 816
VS Dani
15.8 Red Cell Membrane Disorders ........................................................................................................... 820
Rashmi Dalvi, Bharat Agarwal, R Agarwal
15.9 Autoimmune Hemolytic Anemia ....................................................................................................... 822
Bharat Agarwal, Rashmi Dalvi
15.10 Bone Marrow Failure Syndrome ........................................................................................................ 824
Nitin Shah, MR Lokeshwar
15.11 Physiology of Hemostasis: Approach to a Bleeding Disorder ...................................................... 828
Renu Saxena
15.12 Platelet and Bleeding Disorders ......................................................................................................... 831
VP Choudhry, Amit Upadhyay
15.13 Disseminated Intravascular Coagulation (DIC) .............................................................................. 843
Anupam Sachdeva, VP Choudhry
15.14 Bleeding Disorders in the Newborn .................................................................................................. 854
Jayashree A Mondkar, Mamta Manglani, Armida Fernandez
15.15 Hematopoietic Growth Factors ........................................................................................................... 858
Purvish M Parikh, MR Lokeshwar
15.16 Transfusion Medicine and Component Therapy in Pediatrics ..................................................... 861
RK Marwaha, Sudeshna Mitra, Deepak Bansal

16. PEDIATRIC ONCOLOGY

Chapter Editor: Purna A Kurkure
16.1 Malignancies in Children .................................................................................................................... 874
Purna A Kurkure
16.2 Acute Leukemia ..................................................................................................................................... 874
Anupama Borker, SH Advani
16.3 Hodgkins Disease ................................................................................................................................. 880
Purna A Kurkure, Brijesh Arora, Roshni Bhagwat

Contents XLIII
16.4 Non-Hodgkins Lymphoma .................................................................................................................
Purna A Kurkure, Brijesh Arora, Roshni Bhagwat
16.5 Wilms Tumor .........................................................................................................................................
Purna A Kurkure, Brijesh Arora, Shailesh Kanvinde
16.6 Neuroblastoma .......................................................................................................................................
Purna A Kurkure, Brijesh Arora, Shailesh Kanvinde
16.7 Soft Tissue Sarcoma ..............................................................................................................................
Sajid Qureshi, Purna A Kurkure
16.8 Retinoblastoma ......................................................................................................................................
Sripad Banavali
16.9 Bone Marrow Transplantation ............................................................................................................
Brijesh Arora, Purvish M Parikh, MR Lokeshwar

883
887
890
895
901
903

Volume 2
17. ENDOCRINOLOGY
Chapter Editor: PSN Menon
17.1 Disorders of Growth ............................................................................................................................. 912
PSN Menon
17.2 Disorders of Pituitary ........................................................................................................................... 919
PSN Menon
17.3 Obesity ..................................................................................................................................................... 925
Anju Virmani
17.4 Disorders of the Thyroid Gland ......................................................................................................... 931
Meena P Desai
17.5 Disorders of Bone and Mineral Homeostasis .................................................................................. 935
Vijayalakshmi Bhatia
17.6 Disorders of Puberty ............................................................................................................................. 941
Prisca Colaco
17.7 Disorders of Sexual Differentiation .................................................................................................. 947
P Raghupathi
17.8 Disorders of Adrenocortical Biosynthesis ........................................................................................ 951
P Raghupathy
17.9 Disorders of Adrenal Glands .............................................................................................................. 955
PSN Menon
17.10 Diabetes Mellitus .................................................................................................................................. 962
Vijayalakshmi Bhatia

18. GENETICS
Chapter Editor: ML Kulkarni
18.1 Basic Genetics for Genetic Counseling ............................................................................................. 972
ML Kulkarni

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IAP Textbook of Pediatrics

18.2 Common Genetic Disorders ................................................................................................................ 989

ML Kulkarni
18.3 New Genetics and Advances in Genetics ....................................................................................... 1013
ML Kulkarni
18.4 Inborn Errors of Metabolism ............................................................................................................. 1029
ML Kulkarni

19. CHILDHOOD DISABILITIES

Chapter Editor: MS Mahadeviah
19.1 Developmental Disabilities in Children ......................................................................................... 1044
MS Mahadeviah
19.2 Cerebral Palsy ...................................................................................................................................... 1045
Pratibha D Singhi
19.3 Attention Deficit Hyperactivity Disorders ..................................................................................... 1049
Nandini Mundkur
19.4 Learning Disability ............................................................................................................................. 1051
MS Mahadeviah
19.5 Childhood Autism ............................................................................................................................... 1053
MS Mahadeviah
19.6 Early Detection and Early Intervention Therapy for Developmental Delay ........................... 1055
MKC Nair, Babu George
19.7 Mental Retardation ............................................................................................................................. 1072
Sunanda K Reddy

20. PEDIATRIC IMMUNOLOGY, ALLERGY AND RHEUMATOLOGY

Chapter Editor: Surjit Singh
20.1 Basics of Immune System in Children ............................................................................................ 1080
Keya R Lahiri, Roshani N Taori
20.2 Immunodeficiency Disorders ............................................................................................................ 1085
Surjit Singh, H Paramesh
20.3 Allergic Rhinitis ................................................................................................................................... 1087
H Paramesh
20.4 Food Allergy and Related Gastrointestinal Tract Diseases ......................................................... 1091
VS Sankaranarayanan
20.5 Value of Allergy Tests in Pediatrics ................................................................................................. 1095
L George Moses, A Parthasarathy
20.6 Allergen Specific Immunotherapy ................................................................................................... 1099
K Nagaraju
20.7 Rheumatological Disorders in Children ......................................................................................... 1101
S Ramakrishnan, A Parthasarathy
20.8 Antiphospholipid Syndrome ............................................................................................................ 1112
Surjit Singh
20.9 Approach to Vasculitis in Children ................................................................................................. 1113
Surjit Singh

Contents XLV
20.10 Kawasaki Disease ................................................................................................................................ 1115
Noel Narayanan
20.11 Intravenous Immunoglobulin ........................................................................................................... 1118
Surjit Singh

21. THERAPEUTICS
Chapter Editor: Sandeep B Bavdekar
21.1 Basics of Pediatric Therapeutics ....................................................................................................... 1122
Sandeep B Bavdekar, S Ramesh
21.2 Adverse Drug Reactions, Drug Interactions and Therapeutic Drug Monitoring .................... 1126
Archana Kher, Milind S Tullu
21.3 Rational Drug Therapy in Children ................................................................................................. 1130
Arun Phatak

22. PEDIATRIC INTENSIVE CARE

Chapter Editor: Sunit C Singhi
22.1 The Need and Scope of Intensive Care in Pediatrics .................................................................... 1136
Krishan Chugh
22.2 Organization of a Pediatric Intensive Care Unit ........................................................................... 1138
Sunit C Singhi
22.3 Cardiopulmonary Resuscitation ....................................................................................................... 1141
Yogesh C Govil
22.4 Shock ...................................................................................................................................................... 1148
Jayashree Muralidharan
22.5 Acute Respiratory Failure .................................................................................................................. 1153
Uday B Nadkarni
22.6 Assisted Ventilation in Children ...................................................................................................... 1156
Suchitra Ranjit
22.7 Monitoring a Child on Intensive Care ............................................................................................. 1160
Archana Sathe
22.8 Interpretation of Laboratory Findings in a PICU .......................................................................... 1168
Anil Sachdev

23. ADOLESCENT CARE

Chapter Editor: MKC Nair
23.1 Introduction: Why Adolescent Care? ............................................................................................... 1176
MKC Nair, SS Kamath
23.2 Adolescent Care and Family Life Education .................................................................................. 1178
Manorama Verma
23.3 Adolescent Nutrition .......................................................................................................................... 1180
Jugesh Chhatwal
23.4 Adolescent Psychology ....................................................................................................................... 1183
Jugesh Chhatwal

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IAP Textbook of Pediatrics

23.5 Identity Crisis and Adolescents ........................................................................................................ 1186

Shrikant W Chorghade
23.6 Adolescent Sexuality ........................................................................................................................... 1189
Jugesh Chhatwal
23.7 Common Health Problems in Adolescents ..................................................................................... 1192
Manorama Verma, Jugesh Chhatwal
23.8 Polycystic Ovarian Syndrome ........................................................................................................... 1200
MKC Nair

24. ACCIDENTS AND POISONINGS

Chapter Editor: CG Wilson
24.1 Injuries in Children and Injury Control ......................................................................................... 1204
CG Wilson
24.2 Poisoning in Children ......................................................................................................................... 1207
KS Rao, B Ravichander

25. CHILD PSYCHIATRY

Chapter Editor: Manju Mehta
25.1 Child Psychiatry ................................................................................................................................... 1216
Manju Mehta
25.2 Child Guidance Clinic (CGC) ........................................................................................................... 1229
T Ravikumar

26. PEDIATRIC SURGERY

Chapter Editor: Ketan Praveen Parikh
26.1 Common Pediatric Surgical Problems ............................................................................................. 1232
Subhash J Dalal, Ketan Praveen Parikh, Amrish Vaidya

27. PEDIATRIC ORTHOPEDICS

Chapter Editor: Mayilvahanan Natarajan
27.1 Congenital Anomalies ........................................................................................................................ 1264
PP Kotwal, Bhavuk Garg
27.2 Infections of Bones and Joints .......................................................................................................... 1268
PP Kotwal, Bhavuk Garg
27.3 Neuromuscular Disorders .................................................................................................................. 1278
Mayilvahanan Natarajan
27.4 Osteochondritis .................................................................................................................................... 1282
Mayilvahanan Natarajan
27.5 Inequality of Limb Length ................................................................................................................. 1285
Mayilvahanan Natarajan, PP Kotwal, MK Varshney
27.6 Pediatric Bone Tumors ....................................................................................................................... 1288
Mayilvahanan Natarajan, PP Kotwal, MK Varshney
27.7 Miscellaneous Orthopedic Conditions ............................................................................................ 1296
PP Kotwal, MK Varshney

Contents XLVII

28. PEDIATRIC RADIOLOGY

Chapter Editor: Arun Kumar Gupta
28.1 Pediatric Radiology ............................................................................................................................. 1300
Arun Kumar Gupta, Chandan B Das

29. PEDIATRIC OPHTHALMOLOGY

Chapter Editor: Supriyo Ghose
29.1 Common Eye Problems in Children ................................................................................................ 1316
Supriyo Ghose

30. PEDIATRIC OTORHINOLARYNGOLOGY

Chapter Editor: Divya Prabhat
30.1 Common Problems of Ear, Nose and Throat in Children ............................................................ 1334
Divya Prabhat

31. PEDIATRIC DERMATOLOGY

Chapter Editor: Jayakar Thomas
31.1 Skin Diseases in Children ................................................................................................................. 1336
Jayakar Thomas

32. PEDIATRIC DENTISTRY

Chapter Editor: PK Baskar
32.1 Common Dental Problems ................................................................................................................. 1372
PK Baskar

33. PEDIATRIC PRIORITIES IN THE 21ST CENTURY

Chapter Editor: Piyush Gupta
33.1 Pediatric Priorities in the 21st Century ............................................................................................ 1384
RK Agarwal, Piyush Gupta
33.2 Pollution and Child Health in the 21st Century ............................................................................ 1389
NR Bhandari
33.3 Pediatric Environment Health-Hazards .......................................................................................... 1392
Anupam Sachdeva, MKC Nair, Swati Y Bhave
33.4 Research Methodology in Pediatric Practice .................................................................................. 1410
Saradha Suresh, P Ramachandran
33.5 Computers in Pediatric Medicine ..................................................................................................... 1414
Neeraj Jain, Vibha Jain

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IAP Textbook of Pediatrics

34. PEDIATRIC PROCEDURES

Chapter Editors: Piyush Gupta, PSN Menon
34.1 Common Procedures in Pediatric Practice ...................................................................................... 1420
Baldev S Prajapati, A Parthasarathy

35. PHYSICAL MEDICINE AND REHABILITATION

Chapter Editors: A K Dutta, Piyush Gupta
35.1 Physical Medicine and Rehabilitation in Pediatric Practice ........................................................ 1446
Bina Ahuja, AK Dutta
35.2 Chest Physiotherapy in Children ..................................................................................................... 1452
D Vijayasekaran

36. Miscellaneous Topics

Chapter Editors: Piyush Gupta, PSN Menon
36.1 Vital Statistics in India ....................................................................................................................... 1458
Piyush Gupta, HPS Sachdev
36.2 The Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of
Production, Supply and Distribution) Act, 1992 ............................................................................ 1459
SP Srivastava
36.3 Normal Laboratory Values ................................................................................................................ 1465
Piyush Gupta, HPS Sachdev
36.4 Principles of Fluids and Electrolytes in Diarrheal Dehydration ................................................ 1474
S Ramesh
36.5 Drugs and Drug Dosage ..................................................................................................................... 1480
S Ramesh
36.6 Essential Drugs in Pediatrics ............................................................................................................. 1488
Arun P Phatak
36.7 Growth Charts: ..................................................................................................................................... 1490
Vaman V Khadilkar, Dilip Mukherjee, MKC Nair
36.7.1 IAP Growth Charts ................................................................................................................... 1490
Vaman V Khadilkar
36.7.2 Appendix .................................................................................................................................... 1498
Vaman V Khadilkar
36.7.3 WHO Growth Charts ............................................................................................................... 1502
Dilip Mukherjee, MKC Nair
36.8 Safe Injection Practices ....................................................................................................................... 1507
Baldev S Prajapati, Swati Y Bhave, SS Kamath
36.9 Searching and Researching Online .................................................................................................. 1516
Vijay Agarwal
36.10 The IMNCI Case Management Process ........................................................................................... 1522
Harish Kumar, Raju C Shah, Naveen Thacker, Deepak Ugra

Contents XLIX
36.11 IAP Infectious Diseases Chapter Protocols: ................................................................................... 1525
Ritabrata Kundu, Nupur Ganguly, Tapan Kumar Ghosh
36.11.1 Malaria .................................................................................................................................... 1525
Raju C Shah, Tapan Kumar Ghosh, Ritabrata Kundu, Nupur Ganguly
36.11.2 Enteric Fever .......................................................................................................................... 1528
Nitin K Shah, Raju C Shah, Tapan Kumar Ghosh, Ritabrata Kundu, Nupur Ganguly
36.11.3 Pyogenic Meningitis ............................................................................................................. 1531
Veena Kalra, Tapan Kumar Ghosh, Ritabrata Kundu, Nupur Ganguly, Vijay N Yewle
36.11.4 Rabies ...................................................................................................................................... 1534
Tapan Kumar Ghosh, SN Madhusudhana, Shivananda
36.12 IAP Consensus Recommendations on Immunization, 2008 ........................................................ 1538
Tanu Singhal, YK Amdekar, Piyush Gupta
Index ...................................................................................................................................................... 1545

1.1 Importance of Pediatrics: RD Potdar ....................................................................................................................................................... 2

1.2 Attaining Proficiency in Pediatrics: BNS Walia ...................................................................................................................................... 3
1.3 Pediatric Care in Developing Countries: BNS Walia .............................................................................................................................. 5
1.4 Primary Health Care: Yuvaraj Chandra Mathur, Nitin Chandra Mathur .................................................................................................... 7
1.5 Primary Neonatal Care: Santosh K Bhargava .......................................................................................................................................... 9
1.6 Management of Primary Health Centers: Piyush Gupta ....................................................................................................................... 12
1.7 Training of Medical Graduate as Middle Level Manager: C Thirugnanasambandham, T Arunmozhi ............................................... 16

IAP Textbook of Pediatrics

1.1 Importance of Pediatrics

RD Potdar
Till nearly 50 years back, Pediatrics used to be considered
as subsidiary of internal medicine in India and other
developing countries. It was but natural that many
internists while treating children as small adults, realised
that children form a unique, definitive and a fairly large
segment of human population. Some of them started
studying the health and diseases of children exclusively
and in depth and established that Pediatrics was a science
and a subject by itself.
Undergraduate students of Medicine must clearly
understand the attributes, significance, importance and
the necessity of the subject of Pediatrics before they
embark on Pediatrics itself, merely as an examination
subject. Whether they aspire to become specialists in
Pediatrics or its subspecialities or otherwise, knowledge
of Pediatrics is essential for every medical student because
nearly 42 percent of our population is below 18 years and
every physician is bound to face children in his/her
medical career as frequently, if not more often than adults.
It is necessary to know the special situation of
Pediatrics as a subject because of the following reasons:

second hand coming from the caregiver more often than

the child itself.
Many symptoms get converted into presenting features which are a series of common symptoms representing different organ affections or problems as under:
Crying: It is the most common presenting feature of many
conditions such as pain, hunger, thirst, wetting, fear,
anxiety, local hurt, etc.
Vomiting: It may be a presenting feature of any system
malfunction apart from or in addition to gastrointestinal
disease.
Paucity of Signs
One may not be able to elicit all classical signs that can
be elicited in adults. In Pediatrics, clinicians have to use
comprehensive findings of history, examination,
investigations and natural history and course of the
disease to arrive at a specific diagnosis.
Growth and Development

Age Group
Pediatrics, unlike the other subjects includes a wide spectrum of age groups. Each of these age groups have their
own physiological, pharmacological, pathological and
therapeutic characteristics which need to be remembered
while handling respective age groups in clinical
situations. The age groups are: (1) fetal period including
embryogenesis, (2) perinatal period, (3) prematurity,
(4) natal period, (5) neonatal period, (6) infancy, (7) toddler
group, (8) preschool, (9) schoolprimary, middle and
high, and (10) adolescence.
The pattern of health norms, presentation of diseases,
common causes of diseases as well as dosage and tolerance of drugs differ at these ages. Hence, age becomes a
very important consideration in treating a child.

A child is a constantly growing and developing organism making it highly susceptible and vulnerable to
various invasive, diagnostic and therapeutic actions. This
makes the responsibility of the clinician towards the child
far greater than that for the adult. Child is always the
passive recipient of treatment and hardly has any choice
taking any decision concerning itself.
Early Diagnosis and Early Intervention
These have tremendous rewards and importance in
children as compared to an adult, e.g. TB meningitis
suspected and diagnosed at an early stage can prevent
many a tragic sequelae as compared to an adult where
early intervention may not be that cost-effective.

Presenting Features

Drug Tolerance, Interaction and Toxicity

In most pediatric patients, symptoms are not directly

brought out like those in the adults. History is always

It is different for different drugs at different ages of a

child. Since the dosage is related to the body surface or

Pediatric Care in Developing Countries 3

the weight, it is essential that a drug dosage guide
should always be referred to by the treating doctor. The
drug dosage in adults, is generally, in fixed formulation
since there is no extreme variation in all ages of
adulthood unlike the pediatric age group.
Intergenerational Impact
Studies all over the world are proving that impact of
previous generations can manifest in the present generation both as far as genetic and environmental factors
are concerned. New vistas have opened in causation,
prenatal diagnosis as well as therapy in terms of genetic
engineering and gene therapy.

Pediatric Specialties
Even as the science of Pediatrics has come to stay on its
own, further subspecialties are continuously being
developed. Neonatology and Pediatric Hemato-Oncology
as pediatric superspecialties have already been accepted
for DM degree which is a postgraduate qualification.
Other specialties are also increasingly developing.
It may be, therefore, said that Pediatrics, the science
related to children has come of age in 2009 with adolescents forming integral part of Pediatrics, and its importance in India where most young population of coming
century in world will form the major segment.
Pediatrics thus needs a constant attention from all
medical aspirant students.

1.2 Attaining Proficiency in Pediatrics

BNS Walia
The time required for mastery of the art of treatment of
sick children is not proportional to the size of the child vs
the adult human. In fact, it is longer and more arduous.
Physical, physiologic and metabolic growth which is
taking place from birth to maturity as an adult makes the
task as difficult as learning to shoot at a moving target,
which is more difficult than shooting at a sitting duck!
Learning the fundamentals of growth are therefore a
prerequisite key to understanding several aspects of
pediatrics.
Diseases occur in humans and humans are already
nine months old on the day of birth! Therefore knowledge
of embryology and prenatal development not only helps
to understand the genesis of congenital malformations,
but also guides regarding vulnerable periods in the
evolution of a fetus, which may affect its entire life span.
Osler had said that a physician is as good as his
pathology. Knowledge of underlying pathology is
important to understand the symptoms observed in a
disease process and help to understand its evolution.
A sound knowledge of pharmacology helps one to
choose the right drug in the right dose. Medicines are
the main armamentarium of a physician. He must be
aware of what is available, but he must also find out more
about their indications, contraindications, side effects,

interactions and dosages before he uses any. This applies

especially to uncommonly used drug.
Amongst the common drugs, about which a doctor
is expected to be well informed, suffice it to say that you
need not burden yourself with the names and details of
all the brands of a molecule available in the market. Select
some reliable brands and stick to them. It has been well
said that drugs are like friends, which must be chosen
wisely and once trusted, kept close to ones bosom.
The basic sciences enable you to understand the why
and how of clinical phenomena and therefore must form
the core foundations for your clinical progress. The
foundation must be deeper, the higher the structure you
wish to construct upon it.
The clinical years are the most interesting period of
medical studies. Learn first of all how to take a good
clinical history. A well recorded history should not only
provide clues to diagnosis and differential diagnosis but
also how the patient has responded to the treatments
offered so far as well as how advanced the condition is
and what the prognosis might be. This must be followed
by a complete and thorough examination of the patient
howsoever minor the complaint that brings him to you.
Many a time you may be able to detect a corroborative
sign or another disease, which is unrelated with the
presenting symptoms.

IAP Textbook of Pediatrics

Though the method of systemic examination of a child

is in no way different from that of an adult, the order of
examination should begin from least discomforting
aspects. Also several differences exist in the interpretation
of physical signs when seen in a child as compared to an
adult e.g. tremors in a newborn, brisk tendon reflexes in
a child, extensor plantar response, presence of bronchial
breathing in interscapular region or even presence of
palpable liver in childhood! You must be aware of these
differences and every book on physical examination of
the child emphasizes these.
A special effort must be made to learnsome special
aspects of physical examination in pediatrics. These
include examination of newborn, assessment of
gestational age of a neonate and toddler, neurological
examination of a neonate, developmental assessment,
assessment of growth and sexual development. Identification of signs of nutritional deficiency and ability to
conduct neurological examination of a preschool child
also require special attention.
Whereas theoretical knowledge is best obtained as
described above, clinical skills are acquired by seeing
someone perform the clinical examination. Excellent
audio and video recordings are now available to practice
clinical skills, after seeing these videos. It is important
that some one should watch you while you are performing the developmental examination of a child or
maturity rating of a newborn infant. Both of you should
point out any faults of the partner and if necessary settle
your doubt by asking the advice of a person senior to
you. Later on practice case presentations to each other
and correct each other on history taking, clinical skills.
Make a provisional diagnosis and be able to justify it on
the basis of history and clinical sign. It is essential to write
down a provisional diagnosis or the next best possibility,
so that if you are proved wrong, you can go back to the
case and reexamine it to see what you had missed to do,
which resulted in a diagnostic error. Do not be depressed
if you are proved wrong. Only the persons, who do not
commit to a diagnosis, never make a mistake. Clinical
pediatrics is not like mathematics. There is a lot of
intelligent guess work involved depending upon family,
occupational history, epidemiologic conditions and
prevalence rates of different diseases in a country. But at
all times remember that an uncommon manifestation of
a common disease is more likely to be the cause of a
difficult diagnostic riddle than a rare disease. When faced
with a difficult diagnosis sit down with a list of
possibilities which can be considered in the differential

diagnosis. Score out those that have features that do not

fit and start investigating for those conditions, for which
the clinical possibility exists. Arriving at a diagnosis
should not be like searching for a needle in a haystack
but on the other hand, it can be compared to a concerted
pursuit of a crime investigator who is gathering evidence
against suspects, to whom the needle of suspicion points.
Inspite of learning all that is said above; your training
will be still far from complete. The ability to interpret
findings on otoscopy and fundoscopy may have to be
learnt by visits to the special clinics of department of ENT
and Ophthalmology. A week spent in the department of
dermatology will familiarize you with the common
dermatological problems seen in pediatrics. Similarly,
one requires interactions with a child psychiatrist to
understand identification and management of behavior
disorders which may masquerade with somatic symptoms.
Cardiopulmonary resuscitation should be learnt on
a mannequin before you enter a clinical ward. Who
knows you may be required to resuscitate a baby on your
first night duty, because none else is available!
Competence and confidence in performing procedures is acquired only by doing the procedures. The more
you do, the more proficient you become. There is no place
for complacency in dealing with sick children. If you do
not know how to do a procedure competently, refer the
patient to someone who can. If you mess up the life or
limb of a child, remember, there is COPRA waiting to
sting you!
Basic science related to the disease conditions you are
being taught in clinical pediatrics must be revised at the
same time. For instance study of diseases of thyroid
should start with embryology and anatomy of thyroid
gland, the biochemistry related to synthesis of thyroxin
and proceed with clinical manifestations of thyroid deficit
or excess. This will enable you to understand why and
how certain clinical features of the disease manifest.
Information on developmental testing will enable you
to pick up children who are slow in their development.
Read about the growth parameters at the relevant age
and about procedures of bone and sexual maturity rating.
Next assess your patient. Make a diagnosis and write
down the suspected cause for the abnormality. Read
about what tests are best for establishing the diagnosis
and for repeated evaluation. Now look at treatment
options. Talk to parents of the child on how to use the
medicines and what response to expect. Explain why
medicines must be continued for life time in a dose that

Pediatric Care in Developing Countries 5

may vary depending upon patients response. Inform
parents when to suspect side effects of drugs and when
to come for follow up to evaluate that the medicines
prescribed are acting and there are no adverse side
effects. This is just an example of how medicine should
be studied and practiced to obtain a clear idea of what
needs to be done and its scientific basis. Studied in this
way a proper understanding of medicine is obtained and
once understood, it is retained for a long time. The above
described method may appear to be too time consuming,
but infact, each aspect reinforces the other and the whole
exercise becomes enjoyable when you understand its
why and how.
When bored or tired pick up any of the numerous
atlases available on different subjects or Caffees book
on Pediatric Radiology. Several websites also have
excellent picture collections. Look at the pictures and try
to store these images in your memory bank. You will be
surprised at your own memory which will download a
picture several years later and provide you a diagnosis.
Even a life time is not enough to attain mastery over
entire field of pediatrics but if you can master the
diagnosis and treatment of about 50 clinical conditions,
you will be known and respected amongst your
colleagues as a competent pediatrician. Surely that is not

asking for too much. Each one of you has the potential to
achieve that status, provided you focus, continue efforts
to improve your skills and have the humility to learn
from anyone who knows more than you.
Watch the bedside manners of your seniors who are
popular with patients. Note how they approach the
patient and the way they interact with parents. When
social competence combines with clinical competence,
nothing can come between you and success. A friendly
helpful and sympathetic attitude is essential at all times
for building good relationships that last. Never exploit
the misery of a patient who is already in distress.
Remember always that a patients best interest must be
first and foremost in your mind.
What you learn at the medical school is a minuscule
of the vast ocean of knowledge. You mainly learn to
acquire knowledge and some practical skills, which will
form the foundation of your future career. What you
build on it depends on the inputs of hard work,
methodically carried out over span of a life time. A life
time is too a short period to master even one specialty or
sometimes even one medical disease, but if the quest is
continuous, you will enjoy the journey, whatever be the
distance you cover.

1.3 Pediatric Care in Developing Countries

BNS Walia
Most of the developing countries suffer from the twin
scourges of large populations, with vast numbers living
in dire poverty and subhuman living conditions. More
than half of the population lives below the breadline,
which leads to nutritional deficits. Frequent episodes of
infectious diseases further sap away the already poor
nutritional status.
Adding to these widely prevalent disadvantages are
the complexities of living in deep interiors of countryside,
where means of transport are either scarce or nonexistent,
health centers are miles away and health service
providers are either unskilled or not available at all. These
people live on the edge, where ruthless nature and state
of neglect takes a heavy toll on the weak and the
vulnerable, i.e. women and children. Modern medical

care is a distant dream and mere survival is a boon from

the Gods.
How and why the situation has been allowed to
deteriorate to this extent, is an uncomfortable question.
The answer lies in the wrong policies pursued by the
government of most of the developing countries, with
few exceptions. Over the last few decades, these policies
have led to a grave imbalance in the allocation of funds
for health projects, so that urban health has been given
precedence over health of rural populations which
constitute 7580 percent of toal population of a country.
Hospitals have been preferred to dispensaries and
maternal and child health (MCH) centers; superspecialty
hospitals devoted to cardiology and neurology have been
given priority over general hospitals, production of

IAP Textbook of Pediatrics

doctors have been given precedence over availability of

paramedics. This imbalance in the disbursement of scant
resources has resulted in a situation, where the interests
of many have been sacrificed for the sake of the few. Thus,
a vast number of people get no medical care. Hospitals,
and dispensaries have been starved of supplies. Doctors
and their overproduction have culminated in a situation
where doctors have to join the queue of educated unemployed, whereas the country is facing grave shortage of
nurses, physiotherapists, speech therapists, audiologists,
radiographers and laboratory technicians.
A young doctor who begins a career in medicine has
to be aware of these shortcomings in the system into
which he has stepped, so as to be able to chart his way to
be able to accomplish his lifes mission in a meaningful
way. The first few years of his professional life are to be
spent in a rural dispensary or a health center, where
leading a health team is going to be his most important
task. It is quite likely, that he will discover that his 5 years
at the medical college did not prepare him to effectively
cope with his responsibilities. The first lesson that he
learns is that he has to learn a lot and that this learning
shall continue throughout life. He also feels, that his teammates also, either do not know how to do what is
expected of them or are not motivated to do it. Setting
standards, and training each member of the team to fulfill
his role, meeting the standards expected, is his next
important task. Knowing the epidemiologic profile of the
geographic area where he is located, helps him to set his
priorities correctly and equip himself with medicines and
supplies for geographic pathology pertaining to that area.
Having ensured himself of a constant supply line of
medicines and other articles needed, he has the
wherewithal to get started. However, his success is
determined by the response that he gets from the
populace and its local leaders.
Illiterate, ignorant of the miracles which modern
medicine can perform, suspicious of new experiments
to be conducted by strangers and misguided by the
indigenous quacks whose vested interests, threatened by
the availability of effective medical care to population
where the quacks hold a monopoly, the villager is often
confused as to where to seek medical relief, even if he is
convinced of its greater effectiveness. There are several
hurdles to cross before he can reach a primary health
center. These include: inability of women folk to travel
alone; (none to care for children and animal stock left
behind while the family is away), loss of a days earnings;

lack of means of transport; and finally the cursory and

callous behavior of health workers, who are generally
overworked and steeped in their own professional and
domestic worries connected with rural living.
The prescriptions obtained after much effort are often
not purchased because the poor patient cannot afford
them or they are not locally available. Compliance with
a full course of treatment is often neglected because
instructions are not clearly given or understood and relief
of presenting symptoms is mistaken as cure. This often
leads to disastrous results in diseases like pulmonary
tuberculosis, where bacteria are liable of becoming
resistant to commonly used drugs. Supervision of
therapy by domicilliary visits of health staff, is often
lacking as numerous vertical programs functioning in
the health services encourage an attitude amongst
workers of doing their bit for their own program and
ignoring the other multiple problems being faced by the
patient. Thus, a leprosy worker will not take a malaria
slide or look at a conjunctivitis eye, because his target is
leprosy eradication. The same is true for workers engaged
in blindness control, reproductive health or malaria
eradication. Whereas most of the world is depending on
the single window approach for numerous public
services, we are going on opening new windows,
serviced by one disease specialists who fail to relate
with their clients, and thus fail to win their confidence.
It is often forgotten that advice on promotive health care
programs, e.g. family welfare which forms a predominant part of primary health care, can only be accepted
by a woman from a health worker who has helped her
to recover from her last episode of dysentery or assisted
her last delivery, and not from a stranger, who is chasing
her for his personal targets. The recent change in the
objectives of the family welfare program to reproductive
health program, is indeed a welcome step and is expected
to divert the attention of workers from achievements of
targets to quality services, to be provided to their clients.
Imparting health education should be an important
task of every health worker. He must try to impart some
messages related to the problems the patients are facing,
at every encounter. This is the only way to counter the
scepticism rooted in age-old beliefs in witchcraft and
supernatural powers. All traditional beliefs may not be
harmful and some indeed may be beneficial to the
patient. Unnecessary confrontation of views should be
avoided.

Pediatric Care in Developing Countries 7

Patients are often brought late to the hospital, and in
a critical condition. Their patience as well as their financial resources get exhausted. Promptness in attending to
the patient, politeness in dealings, and an attitude of
concern and care by the staff is essential. Our patients

believe us to be Gods, and not mere Docs as

compared to our co-professionals in developed countries.
We must try to live up to the expectations of the people,
by showing compassion, and concern, in our dealings
and competence in our jobs, to deserve that appellation.

1.4 Primary Health Care

Yuvaraj Chandra Mathur, Nitin Chandra Mathur
All countries of the world are concerned about the
problem of primary health care (PHC) for their people.
This concern includes such aspects as how to provide it,
how to achieve coverage for all of the people, how to
provide primary health care of some quality, how to
make the maximum use of the countrys and communitys existing resources, both personnel, equipment, and
supplies, and how to link up primary health care at the
local community level with secondary and tertiary health
resources.
It is for these reasons that the international conference
on primary health care was held by the World Health
Organization at Alma-Ata in 1978.
Definition
Primary health care is essential health care made universally accessible to individuals and families in the
community by means acceptable to them, through their
full participation and at a cost that the community and
country can afford. It forms an integral part both of the
countrys health system of which it is the nucleus.
Content
Primary health care addresses the main health problem
in the community, providing promotive, preventive
curative and rehabilitative services accordingly. Since
these services reflect and evolve from the economic
conditions and social values of the country and its communities, they will vary by country and community, but
will include at least: promotion of proper nutrition and
an adequate supply of safe water, basic sanitation,
maternal and child care, including family planning,
immunization against the major infectious diseases, prevention and control of locally endemic diseases,
education concerning prevailing health problems and the

methods of preventing and controlling them, and

appropriate treatment for common diseases and
injuries.
General Principles
1. PHC should be shaped around the lifestyles of the
people to be served.
2. PHC should be an integral part of the National Health
Care System and other services, in particular supplies,
supervision, referral and technical, and it should be
designed to support the needs at the peripheral level.
3. PHC activities should be fully integrated with the
activities of the other sectors involved in community
development (agriculture, education, public works,
housing, communications).
4. The local population should be actively involved in
planning health care, so that it suits their needs and
priorities. Decisions on what are the community
needs requiring solution should be based upon a
continuing dialogue between the people and the
services.
5. The health care offered should make use of the available community resources, especially those which
have hitherto remained untapped, and should remain
within the limits of the funds available.
6. PHC should use an integrated approach of preventive, promotive, curative, and rehabilitative services
for individual, family, and community. The balance
among these services should vary according to community needs and may well change over time.
7. The majority of health interventions should take place
in or as near as possible to the patients home and be
carried out by the worker most simply (but
adequately) trained to give the treatment in question.

IAP Textbook of Pediatrics

Primary health care is usually delivered by community

health workers. These are public health workers, usually
from the local villages which they serve. They may be
full time or part time, they are usually paid. The PHC
worker needs to understand and be knowledgeable about
the major health problems and needs in his or her
community. For primary health care of women, infants,
and children, the traditional birth attendant (TBA) has
been the person providing primary health care in the
villages.

mother who raises and cares for the children, as well as

other family members. It is the mother who usually cooks
the food and feeds the family. It is she who observes the
condition of children, and who notices and attempts to
treat illness in the children. This means that women of
the family need to have a good working knowledge of
health care, including hygiene, feeding, family planning,
and how to follow the childs development and recognize
the signs of early illness. Health education as well as
general education of women is essential. Womens
organizations can play an important role in this matter.

Training of Primary Health Care Workers

The Risk Approach

In order to provide safe basic PHC, one of the early steps

required is to define the roles, duties, and functions, the
PHC worker is expected to carryout this job description
for the community health worker then needs to form the
basis, for the content of the training program for the PHC
worker. This also means that the workers/trainers of the
PHC need to be prepared in the appropriate content
expected of the PHC staff.
Not only appropriate teaching/training of the PHC
staff is essential, careful supervision of the PHC staff is
also essential on the job. Responsibility for their supervision needs to be clearly delineated. The supervisors
need to be familiar with the job description of the PHC
staff, and with the content necessary to supervise them,
as well as methods of supervision.
In a similar fashion, there needs to be a job description of traditional birth attendants (TBAs). Courses for
TBAs need to contain content to enable them to provide
good safe basic prenatal, labor and delivery, and
postpartum care for the mother. They need to be able to
teach and carry out principles of safe hygiene, and health
education for mother and baby. They need to be taught
the principles and content of safe care of the newborn,
of observation of the infant, and of breastfeeding, and
carefully timed supplementary food and weaning. They
need to be trained in family planning education, and in
well child supervision of the infants and children.
Besides, all PHC staff need to be well-trained in the
content of prenatal, intrapartum, postpartum, family
planning, and child health care.

PHC workers need to be taught and be able to utilize the

risk approach. This consists of the ability to follow
carefully and observe pregnant women, infants, and
children, for symptoms/signs/risk factors which might
lead to suspect the presence of a potential health problem
requiring special care and referral. The concept of highrisk at a simple basic level needs to be taught to PHC
workers. Risk factors recognizable by the PHC worker
need to be included in the training of PHC staff. Patients
suspected of being potentially at high-risk need to be
observed and followed more carefully. Arrangements for
quick referral of high-risk patients are essential.

Who Provides Primary Health Care?

Role of Family Members, Especially the Mother

Family members, especially the mother, are often the
main providers of health care for the family. It is the

Linkages to Secondary and Tertiary Care,

Referral System, and Transport
Patients suspected of high-risk need to be referred to a
resource available to the community, able to provide
special diagnostic treatment, and management service
and care, especially a health center or local/district
hospital. A referral system needs to be established so that
easy, smooth, quick and efficient referrals may be made
through a prearranged system. Quick safe transport is
an important aspect of such a referral system.
Indicators of Care and Outcome
As with any activity in public health practice, evaluation
of results is essential for primary health care. Record
keeping is essential. The use of home-based mother
health records is being tested. The development of a
system and of indicators is an important aspect. Basic
indicators such as accessibility to health care, births
attended by a trained attendant, access to safe drinking
water, level of immunization, contraceptive prevalence
are frequently utilized to evaluate outcome of PHC.

Pediatric Care in Developing Countries 9

1.5 Primary Neonatal Care

Santosh K Bhargava
Primary Neonatal Care
The sustained decline in infant mortality rate, caused
largely by a decrease in post-neonatal period mortality
has focussed attention to neonatal mortality and newborn care. If the national goals in child health care are to
be achieved then it is essential to improve neonatal care
at all the three levels namely primary, secondary and
tertiary level. The primary neonatal care deserves highest
priority as even today more than 75 percent of births occur
at home in both urban and rural community and are
attended by trained or untrained birth attendants.
Primary care is intended for all parturient mothers and
their offsprings irrespective of rural or urban community,
institutional, hospital or home delivery for successful
outcome of pregnancies. To achieve this and the birth of
a healthy newborn it is necessary to care and improve
essential prenatal, intranatal, and postnatal care to an
expectant mother and neonatal care at birth subsequently.
Antenatal Care
The most crucial period for a parturient mother and her
fetus is the antenatal period because it is during this time

inappropriate or inadequate care may result in problems

to both. All pregnant women should have access to
antenatal care by trained health professionals. It should
include assessment of maternal health, including weight,
height, midarm circumference, nutritional assessment,
obstetric history and obstetric examination for intranatal
risk, follow-up for pregnancy complications such as
anemia, hypertension, urinary infection, etc. and
assessment for fetal growth. Figure 1.5.1 provides a plan
for antenatal care. In our limited resources it is essential
to categorize a pregnancy at low or high-risk because a
timely referral of a high-risk pregnancy for appropriate
care will prevent adverse outcome. Simple information
such as bad obstetric history, maternal weight less than
45 kg, height less than 140 cm, birth interval of less than
2 years between two successive pregnancies, pregnancy
complications, etc. are indicators of high-risk mothers.
Intranatal Care
Safe and clean delivery remains the main objective of
good intranatal care. The community must be made
aware and encouraged to use safe delivery kit

Figure 1.5.1: Delivery of perinatal care at primary level

10 IAP Textbook of Pediatrics

TABLE 1.5.1: Birth attendants kit of safe
delivery and newborn care

TABLE 1.5.2: Some harmful traditional

practices of newborn care

Soap

Harmful Practices

Plastic sheet

Cotton and gauze pads

Umbilical cord
Cord cutting

Thread or ligature

Razor blade

Mucus suction trap (may be disposable)

Spring balance (reusable)

Measuring tape (reusable, fiber glass)

(Table 1.5.1) and delivery by trained birth attendant.

Hand washing with soap, use of sterile thread and blade,
facilities for oropharyngeal suction and warmth at birth
are key components of ensuring safe birth.
Postnatal Care
A postnatal mother needs to be looked after not only for
postdelivery complications such as bleeding and
infections but also for initiating and maintaining successful breastfeeding. She must be informed about harmful
traditional practices for maternal and newborn care and
advised on routine newborn care.

Cord tying
Cord application

Sickle- or knife-shaped instruments,

bamboo spike
Thread, cloth, bamboo shred
Ghee, turmeric, cow dung, ash

Resuscitation

Slapping, ringing bell, blowing air

across mouth, roasting placenta, etc.

Cleaning oropharynx
Bath

Finger, cloth
Immediately or within few hours of
birth

Prelacteal feeds

Honey, jaggery, glucose, janam ghutti

Time to first feed

Delayed from 6-48 hours or more

Breast milk

Discarding colostrum

Eyes, ear, nose

Kajal and oil application

All newborns irrespective of place of birth, person conducting the birth, whether preterm, term or post-term,
normal or low birth weight, apparently well or sick need
care for their survival and well-being. This care is a
newborns primary need as prior to birth it is wellprotected in safe, sterile and suitably warm in utero
environment. The primary care is thus intended to
support it to establish successfully its respiration, temperature, nutrition and provide safe environment. In our
country almost two-thirds of births occur at home and
the remaining at hospital or health care facility. Thus, a
newborn is to be cared at home by traditional birth
attendants or family and at varying levels of health care
by medical professionals who themselves may or may
not have been suitably trained.

necessary to be aware of these practices, their sensitivity

to the family to provide appropriate beneficial advice
and warning against harmful practices (Table 1.5.2). The
advice for home care should be simple and acceptable to
family. This should include provision of clean birthing
place, delivery by trained birth attendant, use of safe
delivery methods and the mother and the newborn to
be nursed in warm, clean, well-lighted rooms.
The basic features and components of primary
newborn care have been well-defined and accepted for
delivery of newborn care at primary level as a package
comprising of care at birth, in the immediate neonatal
period and subsequently. This package is known and
described as essential newborn care (Table 1.5.3). It aims
to assist the newborn in establishment of cardiorespiratory effort, prevention of hypothermia and maintenance of body temperature, a physical clinical
examination for identification of at risk infant, congenital
malformation; early initiation and maintenance of
successful breastfeeding and referral of a high-risk or sick
newborns for appropriate care to higher level of care.

Domiciliary Care

Care at Birth

The domiciliary care of a newborn is usually determined

by the family tradition, grandmother or any elderly lady
in the house. The family practices are usually steeped in
tradition, cultural and religious practices. It is therefore

The birth of a newborn should always occur in a clean

environment. The room temperature should be suitably
warm. The newborn should be received in a prewarm
clean cloth and dried immediately preferably under a

Neonatal Care

Pediatric Care in Developing Countries

TABLE 1.5.3: Essential newborn care

Care at Birth
Warmth
Initiation and Maintenance of adequate respiratory
effort
Prevention of Infection
Referral for appropriate care

Care During Immediate and Early Neonatal Period

Warmth
Early Breastfeeding
Prevention of Infection
Early diagnosis, appropriate care and referral of a sick
newborn

Care in Late Neonatal Period and Beyond

Follow-up
Intervention

radiant heat source and kept warm. The time to first cry
and breath should be recorded. Most of the newborn cry
immediately at birth. Those who fail to cry may need
resuscitation.
There are several methods to assess the cardiorespiratory effort of the newborn but the most commonly
used method is the Apgar score. The Apgar score consists
of giving a score of 0, 1 and 2 to color, heart rate, reflex
irritability, muscle tone, respirations at 1, 5 and 10
minutes of birth. A score of 7 or more is considered
normal and lower score indicates the need to resuscitate
the infant as described elsewhere. However, at peripheral
level and for primary care health professional such as
traditional birth attendant the time to first cry and
whether it is lusty, feeble or poorly sustained and the
color are reasonably good indicators to reflect newborns
condition at birth.
A clinical examination at the earliest opportunity after
birth is mandatory for all newborns. This is aimed to
identify an infant whether he/she is normal or at risk
and for determining appropriate level of neonatal care.
It is ideal to measure an infant by recording birth weight
or by surrogate to birth weight such as midarm circumference by using measuring tape or bangle. A newborn
is at a very high-risk of acquiring infection and susceptible to adverse effects of cold or hot environment
resulting in hypothermia or fever. It is therefore critical
to ensure asepsis and suitable environmental temperature of 26-28oC for protection of the newborn.

11

Care in Immediate Neonatal Period

Warmth
A newborn continues to remain susceptible to hypothermia and hence it is necessary to provide warmth to
him by radiant heat source such as infant warmers,
lighted bulb or other suitable means such as nursing of
the mother and the infant in same bed. A heat source
should never come in direct contact with the infant or
very close to him as this may cause burn or hyperthermia.
The child should be appropriately clothed.
Early and Sustained Breast Milk Feeding
All newborns should be put to mothers breast as soon
as possible after the birth. Early and sustained breast milk
feeding is vital for a newborns survival not only in the
immediate neonatal period but also in later months. It is
constant suckling of the breast by the infant which results
in successful breastfeeding. In case it is not possible for
an infant to directly breastfeed, the breast milk should
be expressed and the infant fed the same by cup and
spoon. Feeding of a newborn with artificial milk feeds
endangers it to preventable morbidity and mortality.
Prevention of Infection
A newborn is at a very high-risk of acquiring infections
from surroundings and/or by people visiting or handling
him. It is therefore necessary to wash hands with soap
and water before handling the newborn, avoid unnecessary handling by person other than mother or visiting of
the newborn by relatives and friends. All newborn must
be exclusively breastfed and water, prelacteal feeds such
as honey, ghutis, gripe water or unnecessary medication
by mouth must be prohibited. The dangers of such
practices must be explained to family and mother.
Early Diagnosis, Appropriate Care for a High-risk or
Sick Newborn
A good history and clinical examination will help in
identifying almost all at risk and sick newborns. Birth
weight, gestational age, cry at birth, color, movement,
activity, body temperature, abdominal distention,
tachypnea, refusal or decrease in feeds are dependable
signs or symptoms for an early diagnosis. Infants with
birth weight less than 2 kg, preterm irrespective of birth

12 IAP Textbook of Pediatrics

weight, feeble, ill-sustained or excessive crying, poor
color and decreased activity warrant careful observation
and need for appropriate or higher level of supervised
medical care preferably in a health care facility.

nutritional advice, growth assessment, immunization

and for an early diagnosis of developmental delay or
disability for appropriate optimal care.
BIBLIOGRAPHY

Immunization

1.

It is preferrable to immunize the newborn at birth or

within two weeks with oral polio and BCG vaccination.
Hepatitis B vaccine may be administered in high-risk
infants or where the family is able to afford it.

2.
3.

Care in Late Neonatal Period and Beyond

The care of the newborn does not end with the discharge
from the health care facility or postnatal follow-up of
the mother. All infants should be advised adequately on
need to follow-up in well baby/immunization clinics for

4.
5.

Bhargava SK. Recent Trends in Neonatal Health and Care

in India-International WorkshopImproving Health of
the Newborn Infant in Developing countries.
Kathmandu-Nepal, 1997;7-10.
Health Information of India 1994.
National child survival and safe motherhood program,
integrated clinical skills course for physicians, MCH
division, Ministry of Health and Family Welfare, 1993.
National Health Policy, Govt. of India, Ministry of Health
and Family Welfare, 1985.
National Neonatology Forum, Proceedings of National
Workshop on traditional practices of neonatal care in
India, 1991.

1.6 Management of Primary Health Centers

Piyush Gupta
The basic aim of the Primary Health Center is to provide
primary health care to the people it serves.
WHAT IS PRIMARY HEALTH CARE?
Primary health care is essential health care based on
practical, scientifically sound and socially acceptable
methods and technology made universally accessible to
individuals and families in the community through their
full participation and at a cost that the community and
country can afford to maintain at every stage of their
development in the spirit of self-reliance and selfdetermination.
Thus the doctor at a Primary Health Center (PHC)
has a different role to play. He/she not only delivers the
health care but manages the center in totality, trains and
leads the team, involves with the community, gets to
know the local people, geography and epidemiology of
diseases, devises strategy, and coordinates with other
managers and stakeholders (both in public and private
domains) under the jurisdiction of the PHC.
Steps in the Management of Primary Health Care
1. Assessment of the situation
2. Selection of priorities

3. Defining objectives and deciding possible strategies

to accomplish them
4. Involving community
5. Mobilization of resources
6. Selection and training of personnel
7. Identification and supply of essential drugs and
equipment
8. Patient management
9. Monitoring and supervision of the progress of work
10. Team management
Assessment of the Situation
Health situation in the PHC area should be reviewed with
reference to health profile of the people. Availability of
local resources should be estimated. Details of other
demographic and cultural characteristics of the population in the catchments of the PHC should be obtained.
Before hand knowledge of the following factors is
generally valuable in planning out of health facility:
demography (age and sex distribution, spread of
education, average income and economic stratification,
religion and caste groups, cultural beliefs and taboos,
attitudes towards health, expectations from the proposed
health facility and identification of influential as well as

Pediatric Care in Developing Countries

13

functional community leaders), health profile

(prevailing disease pattern, number of people with
disability or handicap, proportion of expectant mothers,
infants and young children; age-related death rates, food
habits, other health practices, the level of sanitation and
hygiene in the community), available resources (the state
of agricultural development and irrigation facilities in
the area, income stratification, availability of food and
sources of potable water, existing health facilities in the
area and their utilization, presence and number of
available traditional faith healers, traditional birth
attendants, practitioners of indigenous systems of
medicine, and information regarding organized
voluntary agencies or establishments such as village
panchayat, health clubs, youth or womens clubs and
other voluntary non governmental bodies), and the
catchment area (geographic terrain, climate, roads and
other means of communication).

needs. It should be possible to quantify the results of

health interventions so that their cost-benefit or costeffectiveness can be evaluated.
An objective may be achieved by several possible
alternate strategies. As a general principle, relatively
inexpensive and flexible strategies should be adopted for
the management of prevalent common health problems.
After carefully reviewing various alternate strategies,
their advantages, disadvantages, cost-effectiveness,
scientific soundness and cultural acceptability, decision
should be made about the activities that should actually
be undertaken in accordance with the declared national
health policy. The decisions should be technically sound
and correct. Possible constraints and obstacles in
implementing these activities should be carefully looked
into. Adequate prior planning should be done by interaction between the community, members of the health team
and the administrative officers.

Selection of Priorities

Community Involvement in Primary Health Care

There may be several compelling health problems

necessitating attention in the territory. With the meager
health resources generally made available through
government agencies for primary health care, every
health need of the community cannot be satisfied. It is
necessary to be selective. The health issues and the target
group of people who merit preferential attention should
be recognized and looked after first. Most people seek
prompt relief from pain and affliction. Provision should
be made for emergency treatment of life threatening
conditions. It is more realistic and expedient to try to
prevent large number of deaths due to vaccine preventable diseases by immunization than using enormous
money to extend the life of a few terminally-sick cancer
patients. Cost effective health interventions should
receive precedence in planning in relation to those
illnesses which though common are hard to prevent or
manage.

Active participation of community in health care is vital

to make health services readily accessible to the people
and for better utilization of the PHC. This approach relies
on creating increasing awareness among local people
about health and health related activities, so that they
can commit themselves and have stakes in the success of
health activities. People should be actively mobilized to
take more interest in development of health services in
their area by explaining the purpose of health activity
and describing an action plan. Individuals who can
assume leadership role are identified. A health committee
should be formed from among these influential
community leaders to analyze health needs of people and
to plan and execute health projects. The committee
should interact with health professionals to find locally
feasible solutions to the identified problems. The
Committee should assess and mobilize resources and
assign responsibility for achieving objectives.

Defining Objectives and Deciding Strategies

Mobilization of Resources

The next step is to identify the objectives proposed to be

achieved through the health care activities. It is not
always necessary to formulate idealistic health objectives.
It is more important to be rational and set objectives,
which are feasible and attainable within a reasonable
time, with the given resources. The objectives should also
be pertinent to the countrys national health policy and

Money, personnel and time are the three most important

resources that need proper mobilization at a PHC. There
should be adequate working space at the health post for
members of the health team to operate from a base.
Means of communication with the referral centers should
also be easily available. A critical minimum amount of
resources is needed to maintain the quality of health

14 IAP Textbook of Pediatrics

services at an effective level. The resources can be
mobilized, either from the government, community, nongovernment-voluntary agencies or recognized international agencies. It is advisable to rely only on those
funding agencies, who assure help on a longterm basis
and who create a permanent infrastructure, so that the
projects aided by them can become self reliant in the long
run.
Selecting and Training Personnel
It is almost impossible for a developing country to
employ fully trained graduate physicians for all aspects
of primary health care. At a PHC, you will need to
delegate some of the simpler health tasks to the
paramedical workers. Increasing dependence on other
categories of personnel with limited on the job training
in specific areas of work becomes necessary. Preferably,
they should be drawn from as well as chosen by the
community they are expected to serve. It does not matter
even if they have a lower academic background. These
paramedical workers will have to be increasingly
employed for assisting the busy and overworked
physician for routine and simpler health related tasks.
The latter will, then be able to devote more of his time
for complex health chores, administration and planning.
It is necessary to supervise the work of these specially
trained health workers and retrain them periodically for
the expected job requirements. Physician should provide
technical guidance and support to these workers. The
training can be extended to the practitioners of
indigenous or traditional systems of medicine, traditional
birth attendants, local priest, faith healer or exorcist in
the village who performs witchcraft, branding or other
rituals; and even the quacks.
Identification and Supply of
Essential Drugs and Equipment
Essential medicines (those that satisfy the priority health
care needs of the population) should be made available
at the PHC. Selection of these drugs also depends on local
health needs and health services. Ensure adequate and
timely supplies of drugs, and immunizing agents. You
should be aware of the sources of supply of drugs and
procedure for ordering these. The requirements of drugs
should be estimated for at least a quarter of the year.
The drugs are best stored in a cool-dry place away from
direct sunlight. Vaccines should be stored in refrigerator

and electricity supply should be ensured. Drugs should

be arranged by their generic names in shelves in
alphabetical order or according to the therapeutic class
(their usage or indications) but not according to the
manufacturer or suppliers. Drugs with a recent date of
expiry should be used early. Record of all drugs should
be kept in a stock book. Drugs should be issued by the
storekeeper to the dispenser against issue vouchers and
an entry should always be made in the stock book and
stock card. Only the minimum essential quantity of drugs
required for use on that day or week should be issued at
a time, to prevent excessive wasteful use and to minimize
the possibility of pilferage.
Medical, surgical equipment, furniture, stationery
and other consumable and nonconsumable stores are also
essential resources for primary health care posts. Nonexpendable stores such as furniture, weighing scales,
bedpans, screens, surgical equipment, microscopes and
motor vehicles if properly handled, are not easily
damaged and can be kept in use for several years. These
should be maintained in working order by regular and
timely repairs. Drugs, food, paper, syringes, laboratory
reagents, kerosene, petroleum, candles, match boxes,
torch cells, cotton wool and surgical dressings etc. are
actually expended and are called expendable stores.
Architecturally, the space within the building should be
so arranged, that it facilitates smooth and orderly work,
and does not cause inconvenience or obstruct the
movement of staff or the patients. A to and fro flow of
patients or a common entrance and exit are not conducive
to good working arrangement. Records and paper work
are essential and unavoidable in a primary health care
setting. Stock books and ledgers have to be maintained
and general correspondence attended. Periodic report of
work is to be submitted to the higher authorities. Poorly
maintained and disorganized records books indicate
poor management, inefficient patient care, inadequate
supervision, mishandling and wasteful use of resources.
Stationery and printed forms should be available for
outpatient registration, treatment, referral laboratory and
X-ray requisition, growth monitoring, immunization and
follow up of special diseases such as tuberculosis and
leprosy. If the primary health care post has some
maternity or general beds, inpatient admission forms,
record forms and discharge summary will also be
needed.
Health care forms should be designed for easy and
effective use. Paper should be used economically, but

Pediatric Care in Developing Countries

there should be enough space for writing the data. A
badly printed form may be used badly, making if difficult
to retrieve useful information.
Patient Management
Disease management is a priority as it relieves distress
of the patient and develops confidence. A delay in
initiation of medical care raises the tensions and temper.
First Aid should be provided promptly. If a patient
requires referral, arrangement for a transfer should be
made, transport arranged and a summary of treatment
received by the patient should be provided. Emergencies
should be given priority. Outpatients should be seen
during a fixed time. Other services, which are not run
on daily basis, should be clearly advertised. A paramedical worker or a physician should be the first person
of contact at the primary health center.
Monitoring the Progress of Work
The leader of the health team is expected to set targets
for different members of the health team. He should
define the tasks to be accomplished within an agreed
schedule of time.
The efficiency of different workers may vary and
certain essential inputs for optimal functioning may not
be available at the appropriate time. To achieve the best
results, you should periodically review the progress of
all work at specified intervals. You should judge the pace
of the work by relating it to the earlier agreed job
schedules, reports of their achievements and site visits
for personal observations and discussion with the staff.
Periodic monitoring helps in recognizing obstacles or
unforeseen difficulties in accomplishing the desired
objectives. Monitoring is useful in good management but
it should be minimal, flexible and timely.
Leading the Health Team
Because of the nature of his training, education and
status, the primary health center doctor has to assume
the role of a natural leader of the PHC team. All personnel
working in the PHC constitutes the health team. As a
team leader, you should be able to induce colleagues and
teammates to work to the best of their capacity, and
motivate them. The team leader should be able to achieve
perfect coordination and cooperation with all members

15

of the team, so that the efficiency and output of the health

team are high and the work is interesting, satisfying and
rewarding.
The leader of the health team should realize that the
health team consists of individuals, who have feelings,
personal interest, anxieties, stresses, conflicts, likes and
dislikes, just as other people. People like to be useful and
important. Their emotional needs are better satisfied, if
they are given the responsibility and authority to carry
out the jobs assigned to them. Their efficiency and work
output improves, if their working conditions are
congenial, peaceful and relaxed with the least tensions
and conflicts. The efficiency of a worker declines if he or
she remains preoccupied with personal needs, such as
lack of adequate lodging close to the place of work, long
hours of work, want of personal security, financial
worries, inadequate facility for childrens education, poor
health or perfunctory personal medical care. It is
distressing to them if their salaries are not paid in time.
Monetary incentive by itself is not adequate for
motivating a health worker to do his work more
conscientiously. Monetary reward should be judiciously
combined with recognition and approbation for his good
work .
The leader should be competent in his own technical
work, so that his team mates respect him for his
knowledge and skills. He should zealously guard his own
credibility for fairness, impartiality, honesty and
integrity. The leader should be easily approachable, so
that the team members can reach him and seek his help
and guidance for solution of their personal, technical and
official administrative problem. The leader should
always appear to be disciplined and well organized in
his thought and work. Delegation of responsibility and
authority to the health team is equally important in the
PHC.
Health team is like a chain: One weak link in the chain
breaks the entire chain. A good leader identifies the weak
links by constant supervision at regular intervals. He then
reinforces them by appropriate measures such as
technical guidance, administrative support and corrective retraining. Regular supervisory control helps the
leader to discover other constraints such as nonavailability or delay in supplies of such needed items.

16 IAP Textbook of Pediatrics

1.7 Training of Medical Graduate as

Middle Level Manager
C Thirugnanasambandham, T Arunmozhi
The World Health Organization, at Alma-Ata conference
on 12th September, 1978, declared that Health, a state
of complete physical, mental and social well-being and
not merely the absence of disease or infirmity, is a
fundamental human right. There is also an increased
realization, backed by scientific evidence, that neither
the individual nor the nation can achieve optimal health
until we tackle what are commonly known determinants
of health-broadly associated with and arising out of
physical, social, economic, cultural and political
environment. The national and state governments are
committed to the achievement of Health for All, as early
as possible through the primary health care approach.
That these efforts have had substantial success can be
seen from some of the indices like reduction in crude
birth rate (CBR) from 40.8 (1951) to 25.8 (2002); halving
the infant mortality rate from 146 per thousand live births
(1951) to 60 (2001); reduction in crude death rate from 25
(1951) to 8.5 (2002); addition of 31 years to life expectancy
from 32 to 64 (2000); and reduction in total fertility rate
from 6.0 (1951) to 3.0 (2000). In spite of these successes,
the unfinished task for achievement is still high as can
be seen from the sociodemographic goals set for the 11th
Five Year Plan. Currently India is committed to become
a developed nation by the year 2020, which calls for very
substantial improvement in health, education, economic
development and other areas. A revised strategy for the
achievement of these goals have also been formulated
and consists of provision of integrated service delivery
for reproductive and child health care; decentralized
planning and program implementation; convergence of
service delivery at village level and empowering women
to function as change agents in addition to being
consumers of health care services; removal of gender
inequalities, and special attention to removing inequity
in health care by focusing services to underserved areas
like urban slums and hilly and tribal areas and
disadvantaged groups like women, female children and
adolescents; diverse health care providers; collaboration
with Non- Governmental Organizations (NGOs);
intensified information, education and communication

activities; intersectoral coordination and providing for

older population. In addition, the strategy provides for
social inputs like increasing literacy and raising age of
marriage. In general, the program will continue to be
community and maternal and child health (MCH) based.
Primary Health Care
The health infrastructure for the delivery of services in
health and family welfare consists of the primary health
care system. Presently, one primary health centre (PHC)
caters to about 30,000 population (20,000 in hilly and
tribal areas), one subcentre to about 5000 population
(3000 in hilly and tribal areas). In addition, there is one
community health centre (CHC) with 30 beds for every
3 PHCs. Both the Taluk and District headquarters
hospitals are being equipped and staffed to provide for
referral services.
Epidemiological Transition
Technological advances in medical and allied sciences
have brought down the mortality rate to the targeted
level, but the morbidity burden on the society continues
to remain high. Both communicable and non communicable diseases rank almost equally in contributing to the
high level of morbidity. An additional challenge is the
wide disparity in health status between states, within
the state and between social groups.
While the disease burden remains unchanged, the
pattern has been changing. It is now certain that the
health challenges for the next few decades will consist
of communicable diseases like HIV/AIDS, drug resistant
malaria, tuberculosis, diarrhea and acute respiratory
infection among children. The second challenge concerns
non communicable diseases like the upsurge of cancer
and cardiovascular diseases and other life-style related
diseases such as diabetes, high blood pressure, mental
depression and suicide and accidents. Increase in tobacco
consumption is a cause for added concern. The spread
of HIV/AIDS has the potential to offset the hard gains
achieved in child survival and life-expectancy.
Widespread malnutrition, poverty and illiteracy, as well

Pediatric Care in Developing Countries

as the generally low status of women impede equitable
health development in the country.
Significant changes have taken place in the health
scenario in the country since independence.
1. The predominantly clinical approach in solving
health problems has given rise to a mix of curative,
preventive, promotive and rehabilitative approach.
2. A huge infrastructure has been created in the rural
areas for delivery of health care and family welfare
services. The workload of the medical officers,
custodian of health in their areas, has very much
increased and consists of integrated curative,
preventive and promotive service delivery. Over and
above, are the essential management functions in
terms of planning, coordination, supervision, training
and others.
3. Renewed emphasis on community involvement,
through the recently introduced Panchayati Raj
system, in planning and implementing various
programs resulting in a need to readjust responsibility
and authority and changes in the working of the
bureaucracy.
4. Integration of a number of vertical programs into the
rural health services.
5. The realization that national/state governments
working through health sector, by themselves can
never achieve the health and demographic goals set.
The private sector, NGOs and sectors other than
health, like education, industry, social welfare, rural
development and civic society can and should play a
critical role in health development. Partnerships with
all sectors of society and at all levels are imperative if
we are to bridge the equity gap in health.
6. Major shift from the clinic-catered approach to one
of a suitable mix of clinic and outreach services.
7. The total expenditure on the health system has been
increasing every year, but has remained static at about
0.9% of the Gross National Product (GNP) over the
past two decades. The current level of expenditure is
inadequate to bring about reduction in infant
mortality rates envisaged under the eleventh plan and
reach the millennium development goals. The
government has planned to increase the expenditure
to 2-3% of GDP by the year 2010 and it is hoped it
will materialize.
The above shifts have resulted in major changes in
the roles and functions of the middle level managers of
health delivery system, particularly of medical officers

17

from that of a pure clinician to include public health

practice, communication and health management.
Health Services Management
A neglected area so far is that of health services
management. The effectiveness and efficiency of the
health care delivery system cannot improve significantly,
unless sound administration or management practices
are adopted to improve the system. It has been the
assumption till recently that persons trained in medicine
or public health automatically qualify to become
managers. Only in the last few years, it has been
recognized that this assumption needs change and good
managers need sound training in principles and practice
of health management or administration.
Administration or management could be defined as
a process by which, the potentials of men, money and
materials are synthesized and synchronized for the
achievement of well-defined goals. It is a way to structure
and direct human groups function cooperatively to
achieve predetermined goals. Generally, administrative
process involves: (i) technical functions, (ii) political
functions, and (iii) conflict resolution functions.
Technical functions are best indicated by the wellknown seven letters namely POSDCoRB: P for planning,
O for organizing, S for staffing, D for directing, Co for
coordinating, R for reporting and B for budgeting.
Political function is not to be conceived as partisan
function of politics, it is concerned with making of
policies and structuring of power relationship in an
organization. Conflict resolution process aims at resolving
conflicts amongst individuals, organizations and
between individual and organization goals.
The middle level functionaries in health system
should possess sound knowledge and skills in the process
of planning, coordination, supervision, training,
monitoring and evaluation, communication, community
participation and management of subsystems like office
management, logistics, budgeting, vehicle management,
etc.
Planning
A plan is predetermined course of action, it involves the
intelligent use of resources and working out the broad
outline of things that need to be done and the methods
for doing them. The middle level managers are concerned
with operational level planning. They are concerned with
area planning, area being determined by geographic

18 IAP Textbook of Pediatrics

jurisdiction of workers and also governed by those of
panchayats and panchayat unions.
The essential steps of planning include collecting
baseline information, setting objectives, deciding on
courses of actions and programming. Monitoring and
evaluation is an integral part of planning. The planning
cycle consisting of: planning, implementation, monitoring, replanning with repeat, contributing to a greater
progress. However, it will also call for increased
managerial skills on the part of medical officers.
Collection of baseline data is a prelude to community
diagnosis which helps to define community health
problems, their severity, place of occurrence, etc. The
process involves decision on information to be gathered,
framing and administration of questionnaire, data
analysis and report writing. Maximum use has to be
made of existing sources of information, restricting
household/community surveys to a bare minimum.
Once the problems are identified, various options to solve
these have to be considered and the ones that are
technically feasible, cost-effective, administratively
feasible and politically acceptable are chosen.
A problem usually encountered at this level is the
need to strike a balance between what community
perceives as their felt needs, epidemiologically determined needs of the area and nationally determined
priority needs. The medical officer will have to feed all
necessary information at this stage to the community and
of which they are not aware of. It has been the experience
that the community will be able to make sound decisions
irrespective of illiteracy, when once they have the
information to base the decisions upon. This way, an
agreed level of needs with priorities could be reached.
Planning process should also ensure that consumer
representatives are involved in the planning process at
every stage. Involvement of community through leaders,
teachers, students and others in the information
gathering process is highly rewarding as it helps to
conserve time and energy and arouses the perceptual
curiosity of the people and successful implementation
of programs decided upon.
Detailed programming for each activity is also part
of planning. Programming calls for decision of the
agencies involved, manpower, roles of agencies and
workers, training, coordination, supervision, logistics,
budget, etc. Finally, program developed for separate
activities are synthesized into a complete plan.

The middle level manager should possess not only

knowledge about planning, but also skills in the planning
process.
Coordination
Health delivery system consists of a number of workers
belonging to different disciplines. Usually, even for
achievement of a single goal, work is divided among
people, resulting in need to secure coordination or
teamwork. Health administration at all levels are faced
with bringing about two types of coordinationintradepartmental and interdepartmental.
Within the present setup, even intradepartmental
coordination is not an easy task to achieve. Integration
of a number of vertical programs into the PHC system
resulting in pooling of workers belonging to various
agencies and changes in their job descriptions and
patterns of work make coordination difficult. A number
of factors like status, beliefs, leadership, clarity of
functions act as major blocks to coordination. The
manager should know various coordinating measures
and which combination to use under particular
circumstances. The measures available to him include
hierarchial control, organizational charts, manuals,
reports, staff conferences, supervision, training,
consultation, etc.
There will be major factors that inhibit interdepartmental cooperation. These should be identified
and solved. Naming a nodal agency for coordination,
nodal officers at various levels, clear definition of roles
of agencies, training, coordinating mechanisms are
important measures to bring about coordination.
Coordination should be in all phases of planning,
implementation and evaluation.
Good coordination also involves getting the right
things done, in the right place, at the right time, in the
right way and by the right people.
Supervision
A major function of medical officers, at intermediate
levels is supervision. It is an educational process in which
the supervisor takes responsibility for helping the
supervisee develop himself and become more competent
in discharging his duties. Supervision aims at goal
achievement, work facilitation and building human
relations. Staff usually look to the manager for a standard
of leadership. Thus, the way in which the managers

Pediatric Care in Developing Countries

conduct themselves, manage a program and its people
will affect how the staff work. It will also influence the
thinking and behavior of future managers. One has to
lead by example for success.
There are a number of supervisory methods, about
which supervisor should be familiar with. These include
individual conferences, staff meetings, in work situations,
evaluations, etc.
Authority and leadership are concepts which
influence supervisory style, i.e. the way a manager
behaves when trying to influence the behavior of
someone else. Authority is the right to command and is
vested in the supervisor by the organization. Leadership
is a process of influence. Supervisory style will fall at
some point in a continuum between authority and
leadership. The mix to be adopted will depend upon the
forces in the supervision and situation.
Appraisal of supervisions should form a basis for
supervision. Apart from ascertaining the quantitative
achievement of those supervised, the supervisor should
know what traits he is looking for in the supervision,
viz., knowledge, quality of performance, ability to learn,
initiative, cooperative attitude, commonsense, etc.
Feedback to staff on their performance is rarely
carried out despite its importance. Clear and direct
feedback induces certainty, solves problems, builds trust,
strengthens relationships and improves work.
Communication
Medical officers, to be effective, must be able communicators. The communication skills has to extend to various
levels. At the first level, being manager, he/she should
be skilled in various methods of official communication.
He/she should encourage vertical communications, both
from top to bottom and from bottom to top and also
horizontal communication between workers at various
levels. Two-way communication should be encouraged
as a rule, since this leads to better understanding and
reduces gaps in communication. As a supervisor, he/
she has to be a good listener. Instructions issued orally
or in writing should be clear and unambiguous.
In dealing with communication with community the
emphasis should be on empowerment of people. People
do take responsibility for their own health, their familys
health and the communitys health, provided they are
given adequate information and technical support.
The communication strategy should be to use a
combined approach of mass media, group and individual

19

approach. Audiovisual aids can help communication

provided they are relevant and used effectively. Villagebased communication should make use of established
channels of communication in the village and of indigenous media. Training of village leaders, individual and
group meetings should be strengthened. Efforts should
be made to utilize workers of health-related developmental agencies having contact at the grass root level.
Training in communication methods and media and
evaluation of their effectiveness should be an integral
part of training.
Teamwork
One of the managerial functions of medical officers is to
promote teamwork. By sharing skills and knowledge as
a team, people can work more effectively than an individual. Teams can work better when members feel accepted
and trust one another, goals are set and tasks defined,
roles are clarified, members listen, communicate and
participate, conflicts are resolved equitably, leadership is
shared and members are mutually supportive. Incentives
for team commitment go beyond salaries. People are also
driven by their pride in producing excellence.
Training
The goal of training is to provide staff with knowledge
and skills they do not have and as such an assessment of
training needs will be the first and useful step, and
managers, employees and clients should be involved. The
training curriculum will depend on the assessment. The
next step is to identify good trainers from within and
outside since a training program is only as-good as the
trainer. Other inputs that need attention are development
of lesson plans, procurement of training materials, place
of training, proper mix of theory and practice, training
evaluation and feedback.
Looking holistically, the medical officers are
concerned with human resources development, for which
training is a tool. Apart from the staff of the health sector,
training has to be imparted to community representatives,
elected representatives of the civic society and others.
Under these circumstances, focus should be on team
training which will contribute to teamwork.
Building Partnership
It is now widely recognized that we must face new
challenges in health that arise out of lack of attention to

20 IAP Textbook of Pediatrics

factors influencing health like poverty, illiteracy,
nutrition, population, globalization, gender inequalities,
pollution and many others. This calls for new forms of
action and the challenge is to unlock the potential for
health promotion inherent in many health related sectors,
societies, local communities, local bodies and families.
Health should be the responsibility of all. The primary
health care system should therefore focus on building
partnerships with all sectors at that level and involve
them in health planning and implementation.
Community Involvement
Involvement of the community both as individuals and
collectively, in the process of decision- making for health
and health development is the essence of community
involvement. They should be responsible for health needs
identification, prioritization of identified needs,
preparation of action plans, monitoring and evaluation.
Community involvement helps in improving coverage,
reduction in inequity and promotion of self-reliance.
Management of community involvement in health
requires both knowledge and skills on the part of medical
officer. The medical officer should be prepared to work
with the people rather than for the people. Success of
community involvement, depends upon a number of
factors. First is political commitment to transfer
responsibility to people. Second is a high degree of
bureaucratic commitment to translate the policies into
action. Thirdly, the role of the agencies shift to one of
directing, supporting and facilitating the process of
community involvement in health. Fourthly, the district
health organization needs to be reoriented to provide the
necessary support. Finally, action is required to
decentralize authority and responsibility to the lower
levels of PHCs and community.
Involvement of women in health care delivery is
crucial as they are the key to primary health care and
general welfare of the communities in all developing
countries and hence community involvement should pay
special attention to participation by women.
Monitoring and Evaluation
Monitoring and evaluation is an important management
activity. It is an integral part of the program plan and
must be built into it. It is an effective tool for testing
program promises, planning and improving the program
performance.

Monitoring generally refers to the .process of checking

the status of the program by comparing the actual
implementation of the activities against work plan,
including the time frame.
On the other hand, evaluation is directed at
measuring progress towards the achievement of
objectives and the impact of the program. Evaluation is
linked to program planning and implementation cycle
and assists the program management in making
midcourse corrections in the program.
The monitoring system should be designed to provide
disaggregated data to reflect the health condition of the
disadvantaged groups, so as to enable to mount more
focused responses to them. This will contribute to
promote equity in health.
To sum up, effective discharge of managerial
functions are critical to the success of all our health and
family welfare programs. Managers have to see that both
the organization and program goals are achieved. No
organization can function without competent managers
and, indeed, in their absence organizations are often
paralyzed or chaotic.
Building up competencies of the medical officers in
the planning process, program implementation,
supportive supervision, training of health care providers,
building partnerships, provision of leadership to health
team, promote social action for health, making the system
responsive to the health care needs of the population,
monitoring and evaluation and many others is therefore
vital. Those competencies are in addition to those related
to making them effective clinicians and public health
program implements.
XI FIVE YEAR PLAN
Monitorial Socioeconomic Targets
Income and Poverty
Accelerate growth rate of GDP from 8 to 10% and
then maintain at 10% in the 12th Plan in order to
double per capita income by 2016-17.
Increase agricultural GDP growth rate to 4% per year
to ensure a broader spread of benefits .
Create 70 million new work opportunities.
Reduce educated unemployment to below 5%.
Raise real wage rate of unskilled workers by 20
percent.
Reduce the head count ratio of consumption poverty
by 10 percentage points.

Pediatric Care in Developing Countries

21

Education

Environment

Reduce dropout rates of children from elementary

school from 52.2% in 2003-04 to 20% by 2011-12.
Develop minimum standards of educational attainment in elementary school, and by regular testing
monitor effectiveness of education to ensure quality.
Increase literacy rate for persons of age 7 years or
more to 85%.
Lower gender gap in literacy to 10 percentage points.
Increase the percentage of each cohort going to higher
education from the present 10 to 15% by the end of
the 11th Plan.

Increase forest and tree cover by 5 percentage points.

Attain WHO standards of air quality in all major cities
by 2011-12.
Treat all urban waste water by 2011-12 to clean river
waters.
Increase energy efficiency by 20 percentage points by
2016-17.

Health
Reduce infant mortality rate (IMR) to 28 and maternal
mortality ratio (MMR) to 1 per 1000 live births.
Reduce Total Fertility Rate to 2.1.
Provide clean drinking water for all by 2009 and
ensure that there are no slip-backs by the end of the
11th Plan.
Reduce malnutrition among children of age group
0-3 to half its present level.
Reduce anemia among women and girls by 50% by
the end of the 11th Plan.
Women and Children
Raise the sex ratio for age group 0-6 to 935 by 2011-12
and to 950 by 2016-17.
Ensure that at least 33 percent of the direct and
indirect beneficiaries of all government schemes are
women and girl children.
Ensure that all children enjoy a safe childhood,
without any compulsion to work.

MDG-THEN AND NOW

Indias MDG 2005 Report Released
On February 13, 2006, the Union Ministry of Statistics
and Program Implementation released Indias first
Millennium Development Goals country report for the
year 2005.
The Millennium Declaration adopted by the General
Assembly of the United Nations in September 2000
committed member countries to achieving eight Millennium Development Goals (MDGs) within a specified
timeframe. The 2005 report on the MDGs gives an
indication of the current status of progress achieved in
the country.
MDG 1: Eradicate Extreme Poverty and Hunger
Indias target: Reduce the proportion of people below the
poverty line to 18.75% by 2015.
Status: As on 1999-2000, the poverty headcount ratio
stood at 26.1%. The share of the poorest quintile in
national consumption is 10.1% for the rural sector and
7.9% for the urban sector. Prevalence of underweight
children is in the order of 47%.

Infrastructure

MDG 2: Achieve Universal Primary Education

Ensure electricity connection to all villages and BPL

households by 2009 and round-the-clock -power by
the end of the Plan.
Ensure all-weather road connection to all habitation
with population 1000 and above (500 in hilly and
tribal areas) by 2009, and ensure coverage of all
significant habitation by 2015.
Connect every village by telephone by November
2007 and provide broadband connectivity to all
villages by 2012.
Provide homestead sites to all by 2012 and step up
the pace of house construction for rural poor to cover
all the poor by 2016-17.

Indias target: Increase the primary school enrolment rate

to 100%, with no dropouts, by 2015.
Status: Dropout rate for primary education during 200203 was 34.89%. The gross enrolment ratio at primary
schools was near 100% for boys and 93% for girls. The
literacy rate (seven years and above) in 2000-01 was
65.4%.
MDG 3: Promote Gender
Equality and Empower Women
Indias target: There should be gender parity in the
number of boys and girls enrolled in schools by 2015.

22 IAP Textbook of Pediatrics

Status: Female-male proportion in primary education is
78:100, and 63:100 in secondary education (2000-01).
MDG 4: Reduce Child Mortality
Indias target: Under-five mortality rate (U5MR) must be
reduced to 42 for 1,000 live births by 2015.
Status: U5MR was 98 per 1,000 live births in 1998-2002.
Infant mortality rate was 60 per 1,000 live births (2003).
Proportion of one-year-old children immunized against
measles was 58.5% (2002-03).
MDG 5: Improve Maternal health
Indias target: Reduce the Maternal Mortality Rate (MMR)
to 109 per 100,000 live births by 2015.
Status: MMR for 1998 was 407. The proportion of births
attended by skilled health personnel was 39.8% in 200203.
MDG 6: Combat HIV/AIDS, Malaria and
other Diseases
Status: The prevalence rate for HIV/AIDS increased from
0.74 per 1,000 pregnant women in 2002 to 0.86 in 2003.
This trend needs to be reversed in order to achieve MDG
6. The prevalence and death rate associated with malaria
is consistently dropping. The death rate associated with
tuberculosis came down from 67 deaths per 100,000
population in 1990 to 33 per 100,000 population in 2003.
The proportion of TB patients successfully treated rose
from 81% in 1996 to 86% in 2003.

MDG 7: Ensure Environmental Sustainability

Status: In 2003, the total land area covered by forests was
20.64%. Reserved and protected forests together
accounted for 19% of total land area. Energy use declined
from around 36 kilogram oil equivalent in 1991-92 to
about 32 kilogram oil equivalent in 2003-04.
The proportion of people without sustainable access
to safe drinking water and sanitation is to be halved by
2015. India is on track to achieving this target, says the
report.
Goal 8: Develop a Global Partnership for
Development
According to the report, developed countries must
provide development assistance to developing countries.
The report says the financial support needed to achieve
targets under this goal for less developed countries and
smaller countries falls short of what developed countries
pledged. It notes, however, that actual disbursements of
overseas development assistance in recent years have
shown a reversal of the declining trend that lasted for
almost a decade since the early 1990s.
In one of the targets under this goalto make
available the benefits of new technologies in cooperation
with the private sectorIndia has made considerable
progress:
Overall tele-density increased from 0.67% in 1991 to
9.4% in June 2005.
Use of personal computers increased from 5.4 million
PCs in 2001 to 14.5 million in 2005.
There are 5.3 million Internet subscribers, as on March
2005 (2.3 Internet users per 100 population).

2.1 History Elicitation: T Ravikumar, C Thangadorai ................................................................................................................................. 24

2.2 Physical Examination and Clinical Skill Development: C Thangadorai, T Ravikumar ................................................................... 30
2.3 Parent Counseling: Parang N Mehta .................................................................................................................................................... 40

24 IAP Textbook of Pediatrics

2.1 History Elicitation

T Ravikumar, C Thangadorai
Treatment begins the moment the family walks in the door.
Richard B Goldbloom
The interview and history elicitation are very important
tools in the field of Pediatric Medicine. Though it is of
much diagnostic value, the very process of interaction
with the parents and the child during history taking also
has therapeutic value. A pleasant and patient interaction
is what any parent desires. There should be fewer distractions during the interview. It is good to use lay terms
when talking to the parents and avoiding medical jargon.
In pediatrics the most important and distinct aspect
is the fact that the person giving the history is usually
not the patient (unless the child is about 4 or 5 years old).
The parents are the usual source of information and in
certain cases when caretakers (other than the parents)
are bringing up the children then they will be the source
of information.
Demography
Make a note of the name of the child, his/her age in years
(with months and days), parents names, address, date
and time of interview, informations name and
relationship to child and their reliability (with regard to
the consistency of the information they provide).
Presenting Complaints
The main problem or complaints for which the child has
been brought for medical attention should be recorded
in the informations own terms and should be recorded
in chronological order with the duration of each
complaint.
Examples:

Fever5 days
Vomiting4 days
Loose motions4 days
Decreased urine output2 days
Lethargy1 day
Fast breathing1 day

History of Present Illness

It is important to gather more information on the specific
complaints mentioned above. Find out the onset of the

complaints (the time up to which the child was apparently

well). The evolution of the problems should then flow in a
clear, concise, temporal sequence, leading up to the present
moment. They should be evaluated in order of occurrence
and an account of any repeated episodes of symptoms
(like seizures or respiratory infections) should be given.
Complications expected for the primary complaint and
other symptoms that will help in detecting associated
conditions and in differential diagnosis should be
enquired. The details of treatment given so far and the
response should also be noted.
Past History
Ask for details of relevant past illness, whose knowledge
will help you in diagnosis or management. History of
occurrence of similar complaints in the past should be
noted. In child with chronic suppurative lung disease or
malnutrition a history of previous exanthematous illness
or whooping cough will help, in failure to thrive a history
of recurrent diarrhea and in a child with fever and fits a
history of febrile fits will be supportive. Past medication
history will also be helpful, for example past history of
antiepileptic drugs or antituberculous drugs [history of
red urine (rifampicin) while on treatment with anti-TB
drugs]. Information on previous significant hospitalizations, accidents or surgeries may also be helpful.
Contact History
History of contact with communicable illnesses (like TB,
chickenpox) must be elicited with tact and patience. It is
often denied and repeated probing with leading
questions may be necessary.
Antenatal History
As many illnesses in children have their origin in the
womb it is important to get a good history about the
period of pregnancy of the index child. Note the three
Is for the mother during pregnancyillness, irradiation and injections (i.e., drugs). Maternal illnesses like
syphilis, toxoplasmosis, AIDS, rubella, cytomegalovirus
and herpes virus infections (STARCH) are associated with
specific syndromes in the child. Folic acid supplementation during early pregnancy (the first trimester) prevents
neural tube defects like meningomyelocele, etc.

History Elicitation and Physical Examination

Birth History
The actual events occurring during delivery must be
enquired. The period of gestation, duration of labor, nature
of delivery, drugs administered during labor and any
complications during delivery (like cord around neck, low
Apgar score) should be noted. The normal first stage of
labor, from the onset of labor pains to the rupture of
membranes, is about 12 to 24 hours and 6 to 12 hours in a
primi and multigravida respectively. The second stage of
labor, from the rupture of membranes to the delivery of the
child, is about 1 to 2 hours in a primi and 1/2 to 1 hour in
a multigravida. The third stage, which is the delivery of
the placenta, lasts about 15 minutes. The duration of every
stage of labor (especially the second stage) is important as
prolonged labor may result in fetal hypoxia.
Postnatal History
The neonate and its state afterbirth should be enquired.
The term of the child, birth weight, cry, activity and color
immediately after birth should be noted. Presence of
jaundice or cyanosis, resuscitation steps used (if any) and
whether hospitalized afterbirth must be detailed. Poor cry
and lethargy suggest perinatal depression. Paucity of
movements of one side or a particular limb may suggest
stroke or birth injury. The sucking effort of a child usually
gives a clue to the neurological status of the child. All
infants pass meconium within the first 24 hours, any delay
would suggest cystic fibrosis while absence of passage
would indicate intestinal obstruction or anal atresia. Most
infants void urine on the first day while all will void within
48 hours, any delay would point towards an obstruction
or agenesis of the renal system.
Developmental History
Development is one aspect of pediatrics that makes it
unique as compared to adult medicine. The developmental
milestones that a child attains are a good reflection of its
physical and neurological maturity. They may be divided
into gross motor (head control, rolling over, crawling,
sitting, standing, walking, etc.), fine motor or adaptive
(grasping reaching tranferring objects, scribbling, etc.),
social (smile, recognition, response to calls, etc.) and
language (cooing, babbling, saying syllables, vocabulary,
etc.). Tailor the development history to the childs age. In
case of more than one child in the family and if the other
siblings are normal, the parents may be asked if the index
child developed similar to the other siblings. The pace of
development differs from child to child. As the child grows

25

older the age range of attainment of specific developmental

milestones usually widens. For example, a normal child
may begin to sit without support between 5 to 8 months as
compared a young infant developing social smile between
6 to 8 weeks. Notice the range of normality becoming more
in the older child. Always tabulate the attained milestones
against the normal age for attainment of that particular
milestone (Table 2.1.1).
Dietetic History
This history is highly problem oriented and age dependent.
Details of the food and dietary patterns help in diagnosing
protein energy malnutrition and failure to thrive. In
addition it helps us to formulate a diet plan for nutritional
rehabilitation of the child for specific diseases. The
calculation of the dietary values of the food consumed
should provide the actual value of proteins, calories and
fats and must mention whether it is sufficient in vitamins,
minerals and other micronutrients. Always state the
amount of calories and proteins the child is getting for
that age as compared to what is expected which will help
us to calculate the calorie and protein gap. Any problem
like feeding difficulty, regurgitation or vomiting should
be noted. Any possible natural toxins in the food consumed
(fungal aflatoxins, copper, etc.) and feeding patterns
during times of illnesses should also be mentioned. In
young children the complete breast-feeding history
including whether colostrum was given, duration of
exclusive breastfeeding, weaning pattern, etc. must be
elucidated. In children given other milk substitutes detail
the type of formula or cows milk, its dilution, bottle or
cup and spoon-feed, frequency and the amount taken
during each feeding (Table 2.1.2).
Family History
The health details of all the family members must be
obtained. This includes their age, sex, present and past
health status, treatment taken and their proximity to the
child. History of similar illness in the family must be looked
for. History of stillbirths or abortions in the family should
be noted (habitual abortions occur in maternal syphilis).
The birth of abnormal or children with illness in the family
and the reasons for death of children or adults at a young
age should be specifically enquired into. The consanguinity pattern with the degree of relationship may be helpful
for genetic disorders. The pedigree chart will help record

26 IAP Textbook of Pediatrics

TABLE 2.1.1: Developmental milestones
Milestones

Gross motor

Fine motor

Personal social

Language

1 month

Grasp reflex

Starts to smile

2 months

Hands closed

Social smile

Cooing

3 months

Head mostly held up but

still bobs forwards

Hand open most often

Sustained social smile

Says aah

4 months

Head held steady

Reaches for objects, grasps

objects and brings to mouth,
hands in midline

Excited at site of food

Laughs out aloud

7 months

Rolls over, creepingcrawling, sits with hands

leaning forwards

Reaches out and grasps larger

objects, palmar grasp, transfers
objects from hand-hand

Smiles at mirror

Babbling

10 months

Sits without support,

cruises

Pincer grasp

Waves bye-bye

Baba, mama

1 year

Walks with one hand held

Releases object to other

person on request/gesture

Plays simple ball game

2-3 words with

meaning

15 months

Walks alone, crawls

upstairs

Tower of 3 cubes

Asks for objects by

pointing

Follows simple
commands

18 months

Runs stiffly, goes upstairs

by holding the rails

Tower of 4 cubes, initiates

vertical stroke scribbles

Feeds self. Dry by day

Speaks 10 words,
Identifies parts of the
body

2 years

Runs well, walks upstair

and downstair one foot
at a time, jumps

Makes tower of 7 cubes,

initiates horizontal stroke

Handles spoon well and

helps to undress

Puts sentence of 3
words

2 years

Goes upstairs with

alternating feet

Makes tower of 9 cubes

Helps put things away

Knows full name

3 years

Rides tricycle, stands

momentarily on one foot

Draws circle, makes tower of

10 cubes, constructs bridge of
3 cubes

Dresses and undresses

fully when helped with
buttons, joins in play

Knows age and sex

4 years

Hops on one foot, throws

ball overhead, climbs well

Draws cross and square, copies

a bridge, constructs a gate of
5 cubes

Plays with several children

with beginning of social
interaction, goes to toilet
alone

Tells story

5 years

Skips

Draws triangle

Dresses and undresses

self, Asks question about
meaning of words

Names 4 colors,
Repeats sentence of
10 syllables

the family history in a pictorial manner helping us to

derive the inheritance pattern of a particular illness.
Usually three full generations are recorded. Individuals
of the same generation should be recorded in the same
horizontal line and numbered from left to right using
arabic numerals. Males are usually placed on the left
side of the pedigree and sib-ship listed in both orders.
The maternal age at the time of child delivery is also
important. Young mothers (less than 18 years) have more
chance of preterm, IUGR babies while older mothers
(more than 32 years) have more chance of having

children with Down syndrome and Klinefelter

syndrome. In children with diseases showing
hereditary traits, an enquiry of a much wider circle of
relatives must be made.
Sociocultural and Economic History
This has a bearing on the type of disease the child might
be suffering from and it also helps in planning
rehabilitation and treatment options in addition to helping
in giving preventive advice.

History Elicitation and Physical Examination

TABLE 2.1.2: The recommended caloric
and protein requirements
Ages

Calories required/day

Protein/day

1 month-1 year

100-110 kcal/kg/day

2 g/kg

1 year

1000 kcal/day

20 g/day

2 year

1100 kcal/day

20 g/day

3 year

1200 kcal/day

20 g/day

4 year

1300 kcal/day

30 g/day

5 year

1400 kcal/day

30 g/day

6 year

1500 kcal/day

30 g/day

7 year

1600 kcal/day

40 g/day

8 year

1700 kcal/day

40 g/day

9 year

1800 kcal/day

40 g/day

10 year

1900 kcal/day

50 g/day

11 year

2000 kcal/day

50 g/day

12 year

2100 kcal/day

50 g/day

Adolescent boy

2400 kcal/day

70 g/day

Adolescent girl

2100 kcal/day

65 g/day

The following points are worthwhile noting:

Type of family: joint or nuclear
Occupation and employment history

Per-capita income (total income divided by the number

of dependent family members)
Type of housing, ventilation, toilet and potable water
facilities
Psychiatric illness and substance abuse (alcoholism,
drugs)
Marital stability
Traditional beliefs and child rearing practices
Immunization History
It is important to record the details of vaccines given to the
child in chronological order. The vaccination schedule of
the Indian Academy of Pediatrics or at least the Universal
Immunization Program should have been followed.
Special vaccines (like pulse polio vaccine) must also be
enquired. Look for BCG scar at the outer aspect of the left
arm at the insertion of the deltoid. If any vaccine has not
been given, note the reason for not doing so.
History of Allergies
It is important to note down any known specific allergies
in the child, either for drugs or food.

2.1.1 MODEL PEDIATRIC CASE RECORD

DEMOGRAPHY
Name: ............................... Date of birth: ...................... Age: ...................... Sex: ...........................
Address: ..........................................................................................................
Informant: ......................... Relationship: ..................... Reliability: ...........
Date and time of examination: .......................................
HISTORY TAKING
Presenting complaints: ...

............................................ History of present illness: ......................................................

Past history: ..................... ............................................

(including treatment history)
Contact history. ...............

27

............................................ Antenatal history:

Birth history: .................... ............................................ Postnatal history:

Developmental history: .. ............................................ Dietetic history: ..
........................................... ............................................ (including nutrition chart)
Family history: .................

............................................ Sociocultural history: .............................................................

Immunization history: ....

............................................ History of allergies: .................................................................

28 IAP Textbook of Pediatrics

PHYSICAL EXAMINATION
General examination:............................................ .............. Vital signs: ...............................................................................
(including ENT, skin, eye, spine and cranium) .................. SMR: .........................................................................................
Anthropometry: ...............

............................................ Developmental assessment: ..................................................

SYSTEMIC EXAMINATION
Cardiovascular system ...

............................................ Respiratory system .................................................................

Abdomen .......................... ............................................ Nervous system ..

PROVISIONAL DIAGNOSIS
Differential diagnosis ....................................................................................
Investigations .................................................................................................
Final Diagnosis ...............................................................................................
2.1.2 MODEL NEONATAL CASE RECORD
DEMOGRAPHY
Name: .............................. Sex: .............................................. Identity number: ............................................
Age (in hours/days/months): .............................................. Date and time of birth: ..................................
Date and time of examination: ... .................... ........................
Name of mother: ................... Name of father: ....................
Address: ................................. Informant: ............................ Relationship: .................................................
Reliability:
CLINICAL HISTORY OF CHILD
Maturity: ................................
Anthropometry: .................... Birth weight: ........................ Length: ............................................................
Head circumference: ............. Chest circumference:.......... .
Presenting complaints: ..........................................................
History of present illness: ......................... Previous illness: .........................................................................
Feeding history: ............................................ Family history: .........................................................................
..................................................................... (including previous congenital anomalies/neonatal problems in siblings)
MATERNAL HISTORY
Age of mother: .......................................... Date of last childbirth: .................................. Blood group: ............................
Para: .......................................................... Gravida: .............. ....................................... Abortions: ................................
Weight of mother: .................................... Nutritional status: ............ Consanguinity:
Last menstrual period: ............................ Expected date of delivery: ............................ Paternal age: ............................
Maternal transfusion: ..........................

History Elicitation and Physical Examination

29

Antenatal period(illnesses/drugs/radiation, etc): ....................

Antenatal ultrasound: ............................. 1st Trimester ........ 2nd Trimester ................ 3rd Trimester .............................
Labor (spontaneous/induced/not known):
Duration of labor: .................................... 1st Stage ............... 2nd Stage ......................
Drugs used during labor (analgesic/anesthetic/others/not known): ..................................
Mode of delivery: ....................................................................
(Spontaneous/manipulated/breech/forceps/vacuum/cesarean/others)
Indication for assistance (if any): ..........................................
Complications during delivery (if any): ...............................
Place of delivery: ......................................
(Hospital/health post/primary health center/private nursing home/others)
Single/twin/others: ..................................... Birth order (if applicable): ...............................
Fetal distress: .........................................
Evidence of fetal distress: ....................
Apgar score: .............................. 1 minute ................................ 5 minutes
Resuscitation: ........................................
(The actual procedures done, in detail)

EXAMINATION OF THE BABY

Neurological sign

Scoring for assessment (shown below):

Posture

External sign
Edema
Skin texture
Skin color
Skin opacity
Lanugo
Plantar creases
Nipple formation
Breast size
Ear form
Ear firmness
Male genitalia
Female genitalia
TOTAL SCORE

Score

Score

Square window
Ankle dorsiflexion
Arm recoil
Leg recoil
Popliteal angle
Heel to ear
Scarf sign
Head lag
Ventral suspension
TOTAL SCORE
Gestational age
(in weeks):

By history:

Impression:
Term/Pre-term/Post-term
AGA/SGA/LGA

By assessment:

30 IAP Textbook of Pediatrics

Nervous system:

GENERAL APPEARANCE
Cry:
Activity/Movement:
Skin:
Head:
Mouth:
Ears:

Color:

Muscle:

Posture:
PROVISIONAL DIAGNOSIS
Face
Palate:
Nose:

Eyes:
Throat:
Neck:

INVESTIGATIONS
FINAL DIAGNOSIS

Cardiovascular system:
(including heart rate, femoral pulse)

BIBLIOGRAPHY
1.

Respiratory system:
(including respiratory rate and pattern)
Abdomen:
Kidney:

Spleen:
Genitalia:

Liver:
Anus:

2.

Limbs and bones:

Feet:

Arms:
Legs:

Hands:
Toes:

3.
4.

Spine and back:

Barness LA. In pediatric history and physical examination.

In McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB
(Eds): Oskis PediatricsPrinciples and Practice, 3rd edn.
Philadelphia, JB Lippincott Williams and Wilkins, 1999;3952.
Harris R. The examination of children. In Swash M (Ed):
Hutchisons Clinical Methods, 20th edn. London, ELBSWB Saunders Co, 1995;365-86.
Rees PE. Evaluating the newborn infant: Diagnostic
approach. In: Pediatric Clinical Skills, 2nd edn.
Philadelphia, Churchill Livingstone, 1997;47-76.
Singh M. Pediatrics clinical methods, 1st edn. New Delhi:
Sagar Publication, 1992;1-94,174-211.

2.2 Physical Examination and

Clinical Skill Development
C Thangadorai, T Ravikumar
The physical examination in a child is distinct in certain
areas from that of the adult. In this discussion, only the
facts that differ from that of an adult examination have
been mentioned. As far as possible, no child should cry
or get irritated while you are examining. If a child cries
when you examine it, then its probably your fault. This
statement by John Apley sums up the care one should
take, while handling the child. There is no definite order
to be followed while examining a child. Individualize
the examination for every child. Do the invasive and
potentially discomforting examinations at the end. Allow
the child to be in its most comfortable position, and place
it in the mothers lap. Both the child and the mother,

must feel secure and confident about the examining

doctor.
GENERAL EXAMINATION
Before starting general examination; analyse the history
and based on that, look for the specific features that you
think to be relevant to the history which will help you to
give a perfect diagnosis. Examining aimlessly is unhelpful,
time consuming and irritating to the child and parents.
General examination must be thorough from head to foot.
Always examine the childs throat irrespective of the
complaint. The golden rule is Head to foot and back, but

History Elicitation and Physical Examination

forget not the ear, throat and urine. The sensorium (e.g.,
stuporous or unconscious in intracranial pathology),
posture and attitude (e.g., frog like and limp in floppy infant),
activity (e.g., apathetic in kwashiorkor), looks (acutely or
chronically ill looking), nutrition (i.e., marasmic,
undernourished or moderately nourished) need special
mention.
Note the shape of the head (Fig. 2.2.1) whether microcephaly, macrocephaly (Table 2.2.1), plagiocephaly
(asymmetrical due to lying of the normal infants with their
heads persistently on one side), scaphocephaly (boat
shaped with increased AP diameter due to premature

Figure 2.2.1: Different shapes of the cranium in a child

31

TABLE 2.2.1: Few of the features to be looked for in the

head and the associated conditions
Features

Few associated conditions

Microcephaly

Familial, craniostenosis, intrauterine

infections,
Trisomy 13 and 21 (Down syndrome)

Macrocephaly

Hydrocephalus, hydranencephaly,
porencephaly, some neurodegenerative
disorders like metachromatic
leukodystrophy, Alexander and Canavan
disease, certain intrauterine infections

Frontal bossing

Rickets, congenital syphilis, mucopolysaccharidoses

Cranio-tabes
(ping-pong skull)
Increased interpupillary distance
(hypertelorism)

Physiological (in preterm), rickets,

Congenital syphilis
Genetic (racial), mongolism
(Down syndrome),
Cri-du-chat syndrome, hypothyroidism

Proptosis
(Sclera is visible
above and below
the cornea)

Thyrotoxicosis, orbital leukemic

deposits, orbital cellulitis,
Arteriovenous aneurysm (pulsatile),
Cavernous sinus thrombosis,
Neurofibromatosis, Crouzons disease

Cataract

Idiopathic, traumatic, intrauterine

infections, galactosemia, diabetes
mellitus, Down syndrome

Mongoloid eyes
(upward slant)

Down syndrome, racial, Prader-Willi

syndrome

Antimongoloid
slant (downward
slant)

Turner syndrome, cri-du-chat

syndrome, Treacher-Collins
syndrome

Depressed
nasal bridge
Low set ears

Down syndrome, mucopolysaccharidoses, hypothyroidism, familial

Down syndrome, mucopolysaccharidoses, Turner syndrome, Potter facies
(renal agenesis)

Facial puffiness

Renal disorder, kwashiorkor, congestive

cardiac failures, angioneurotic edema,
cavernous sinus thrombosis

Large tongue

Hypothyroidism, mucopolysaccharidoses, glycogen storage disorders,

Down syndrome (relative)

Small mandible

Pierre Robin syndrome

Short neck

Turners syndrome, Down syndrome,

mucopolysaccharidoses, hypothyroidism

closing of sagittal suture), brachycephaly (decreased AP

diameter) and oxycephaly (tower-shaped skull).

32 IAP Textbook of Pediatrics

Figure 2.2.2: Method of measuring the size

of the anterior fontanelle

The size of the anterior fontanelle (AF) (about 2.5 cm

2.5 cm) must be measured across the borders as shown in
Figure 2.2.2. It normally closes by 9 to 18 months. Delayed
closure is seen in rickets, hypothyroidism, hydrocephalus,
Down syndrome, achondroplasia and mucopolysaccharidoses. The AF in a quiet child usually shows a very slight
depression from the surface and may pulsate. It is bulging
when the child cries and in hydrocephalus, intracranial
hypertension and pseudotumor cerebri, i.e. after drugs
like nalidixic acid, tetracyclines, steroids and hypervitaminosis A. A sunken fontanelle is a sign of dehydration.
The posterior fontanelle can be felt by running the finger
along the sagittal suture to its junction with the lambdoid
sutures. It normally closes by 2 to 4 months of age. Ridging
and overriding of sutures may normally be seen in the first
few hours afterbirth, due to moulding of the skull during
delivery. It may also be seen in craniostenosis due to
premature fusion of the sutures. Sutures normally get
ossified by 6 months of age (Fig. 2.2.3).
The Macewens sign is useful in clinically detecting
raised intracranial tension after the sutures have closed.
It is the crack pot sound elicited by percussing the skull.
Transillumination of the skull in a dark-room, is useful
in children below one year, to detect subdural effusion or
hematoma, if transluceny extends beyond 2 cm in the
frontal and 1 cm in the occipital region.
The face must be observed for any dysmorphic
features that may suggest chromosomal or developmental
anomalies. Table 2.2.1 shows some common abnormal
features and a few conditions where they are seen. The
inter-palpebral line of the eyes when continued
horizontally backwards, normally divides the ears into
the upper one-third and lower two-thirds. If the line
passes above the ears, it is suggestive of low set ears. The

Figure 2.2.3: The sutures and fontanelles in an infant

neck should be examined for lymph node enlargement,

short neck (normal neck length : height ratio is 1:13) and
low hair line (below C5). The examination should also
include the hair (e.g. pale hair with flag sign in
kwashiorkor), eyes (signs of vitamin A deficiency, icterus,
pallor, etc.) ears (examine tympanic membrane and for
chronic suppurative otitis mediaCSOM), oral cavity
(with special reference to the dentition), extremities (limb
deformities in skeletal dysplasias, widened wrists in
rickets), nails (koilonychia in anemia) and skin for pallor,
icterus, scabetic lesions, impetigo, etc. Fundus examination
is important to make out papilledema, optic atrophy or
retinitis pigmentosa. The mouth is examined for the state
of the gums, dental caries and dentition. Delayed dentition may be familial or due to rickets or osteogenesis
imperfecta.
The correct position for doing the ear, nose and throat
examination is shown in Figure 2.2.4 but this should be
done preferably at the last. While examining lymph nodes,
note the site, size, consistency, tenderness, warmth,
matting and scarring. Always remember to examine the
drainage areas, for focus of sepsis, if there is significant
lymph node enlargement. In older children, discrete and
non-tender lymph node enlargement up to 1.5 cm in the
cervical and inguinal region is not significant.
The skin is examined (Fig. 2.2.5) by rolling a fold of
loosely adherent skin on the abdominal wall between
the thumb and forefinger to determine its consistency,
the amount of subcutaneous tissue present and the
degree of hydration. Examination of the hips must always
be carried out in younger children and infants, to look for

History Elicitation and Physical Examination

33

Temperature above 41C is hyperpyrexia. In conditions

like PEM, where hypothermia is a problem, special low
reading thermometers (30-40C) must be used.
Respiratory Rate

Figure 2.2.4: The correct position of the child for

ENT examination

The rate of respiration in children is important for diagnosing respiratory disease and certain other non-respiratory conditions like acidosis and congestive cardiac
failure. The rate varies in different age groups (Table 2.2.2).
But for practical purposes, the guidelines offered in the
child survival and safe motherhood (CSSM) Program,
serve as a good guide to clinically suspect respiratory
disease (Table 2.2.3).The pattern of respiration must also
be noted whether regular, irregular, Cheyne-Stokes type,
acidotic, etc. In children the respiration is predominantly
abdominothoracic.
Pulse Rate
The pulse is felt mainly over the radial artery at the wrist.
The character, regularity and volume must be observed.
All the peripheral palpable vessels must be examined.
The superficial temporal, carotid, brachial, radial, femoral,
popliteal, posterior tibial and dorsalis pedis arteries are
usually accessible. In infants and very young children, it
may not be possible to palpate the peripheral vessels and
in such situations, the heart rate must be measured using
auscultation. The normal heart/pulse rates in the different
age groups in children are given in Table 2.2.4. For

Figure 2.2.5: The method of examining the skin in a child

with dehydration

dislocation. The Ortolani or Barlow procedure is done

and the typical clunk of the hip moving in and out of its
socket is looked for. Infants and young children do not
exhibit classical pedal edema, but because of this, they are
confined to the bed, sacral edema should be looked for.

TABLE 2.2.2: Normal respiratory rate in

children of different age groups
Age groups

Normal respiratory
rate (Per minute)

Newborn

40

1 year

30

5 years

20

10 years

18

VITAL SIGNS
Temperature
Oral temperature should be taken in children older than 5
years while in infants and younger children the
thermometer may be placed in the axilla, i.e. the groin also
can be used or the rectum. The temperature in the axilla or
the groin is about 0.5C lower and the rectal temperature
about 0.5C higher than the oral temperature. The normal
temperature in children is between 36.5 and 37.5C.

TABLE 2.2.3: Tachypnea indicating significant

respiratory disease (from CSSM program)
Age groups

Respiratory rate
(per minute)

Below 2 months

60 or more

2 to 12 months

50 or more

12 months to 5 years

40 or more

34 IAP Textbook of Pediatrics

TABLE 2.2.4: The normal heart rates in children of
different age groups
Age groups

Normal heart rate

(per minute)

TABLE 2.2.5: Normal blood pressure values in children

Age groups

Blood pressure
(systolic/diastolic)

Newborn

65/45 mm Hg

1 year

75/50 mm Hg

3 years

90/60 mm Hg

Newborn

140

1 year

110

3 years

100

8 years

90

8 years

95/65 mm Hg

10 years

80

10 years

100/70 mm Hg

practical purposes, heart rate of more than 200/minute in

newborns, more than 150/minute in infants and more
than 120/minute in older children can be taken as
significant tachycardia. The radial and femoral pulse must
be palpated simultaneously to look for any radiofemoral
delay. Remember, the heart rate in a struggling or crying
child will be more.
Blood Pressure
Recording of the blood pressure is one of the most
important aspects in a pediatric examination. Yet it is
surprising, how often it is neglected. The correct size of
the cuff must be used, i.e. the cuff should be two-thirds
size of the arm. A large cuff will give an erroneously low
reading while a small cuff will give a high reading. In
infants, the flush method may be used to check the
pressure. Here the childs arm is raised and a tight bandage
is applied up to the level of the cuff so as empty the blood
from the upper limb. Now, the cuff is inflated and the
bandage is removed so that the limb will be pale and
bloodless. Deflate the cuff slowly and note the reading at
which the skin flushes and the limb becomes red again.
This corresponds, approximately to the systolic pressure.
In younger children where auscultation at the cubital fossa
is difficult, the systolic reading obtained by palpation may
suffice. The Doppler technique of measuring blood
pressure is more accurate and can be used in children, if
available. For every pediatric examination, both the upper
limb and lower limb pressures must be recorded to detect
coarctation of aorta while in any child with a suspected
cardiac illness, the pressure must be recorded in all four
limbs. Normally, the pressure recorded in the lower limbs
is about 10 mm Hg higher than the upper limbs. Reserve
recording the pressure to the last in order not to irritate or
scare the child. Normal blood pressure readings in
children in the different age groups is given in (Table 2.2.5).
Normal blood pressure is defined as systolic and diastolic

pressure, less than 90th percentile for that age and sex.
Hypertension is defined as average systolic and/or
diastolic blood pressure equal to or greater than the 95th
percentile for that age and sex, on at least three occasions.
As per the American Heart Associations (Pediatric
Advanced Life Support Course) recommendations, a
formula has been deviced to approximate the 50th
percentile of systolic pressure in children over the age of 2
years [90 + (2 age in years)]. The lower limit of the systolic
blood pressure has been approximated by the formula 70
+ (2 age in years). An observed fall of 10 mm Hg in
systolic pressure suggests a shock.
ANTHROPOMETRY
The measuring of the various anthropometric data is
essential for assessing the growth of the child and its
nutritional status. It is also important for planning the
diet and following up the child especially while recuperating from an illness or during nutritional rehabilitation.
Weight
The child must be weighed during every examination.
The weight of the child is also useful for calculating the
right dosage of the drugs to be given. The newborn loses
up to 10 percent of its weight during the first week, but
regains it in the next few days. The child doubles its birth
weight by 4 months, triples it by 1 year and increases it
4 times by 2 years. For calculating expected normal
weight, the formula shown in Table 2.2.8 may be used.
While interpreting the weight of the child, the present
weight must be compared to the expected weight for age
and the percentage must be calculated in order to find
out which grade of nutrition the child falls under (as per
Tables 2.2.6 and 2.2.7). Weight is recorded on a weigh
scale which should be frequently checked with standard
weights and zero error must be adjusted before weighing.

History Elicitation and Physical Examination

35

TABLE 2.2.6: The Wellcome classification of

nutritional status
Nutritional
status

Expected
weight for age

Presence of
edema

Normal

more than 80%

no

Undernutrition

60 to 80%

no

Kwashiorkor

60 to 80%

yes

Marasmus

less than 60%

no

Marasmic kwashiorkor

less than 60%

yes

TABLE 2.2.7: Indian Academy of Pediatricsclassification of

nutritional status (the prefix 'K' is added to indicate presence of edema)
Level of undernutrition

Expected weight for age

I degree

70 to 79%

II degree

60 to 69%

III degree

50 to 59%

IV degree

less than 49%

TABLE 2.2.8: Weechs formulae for estimating weight and

height for age of normal children
Weights

Kilograms

Pounds

At birth

3.25

age in months + 9

age in months +11

1 to 6 years

2
(age in years 2) + 8

(age in years 5) + 17

7 to 12 years

(age in years 7) + 5

(age in years 7) 5

3 to 12 months

2
Heights
At birth
At 1 year
2 to 12 years

Centimeters

Inches

50
75
(age in years 6) + 77

20
30
(age in years 2) + 30

Height
The height of the child is a good indicator of the chronicity
of any debilitating illness. Height is normally measured
using Herpendens stadiometer. The child should stand
against a wall with his bare feet touching each other, the
heel, calf, buttock, upper back and occiput touching the
wall and the child looking straight ahead. A firm scale is
pressed to the head to mark the point indicating height.
The standing height can be measured for children more
than 2 years old, while for younger children, the recumbent
length should be measured using the infantometer (Fig.

Figure 2.2.6: The infantometer method of measuring

length of child

2.2.6). In exceptions like a child with quadriplegic cerebral

palsy, where the height/length could not be measured,
the length of various segments of the body are measured
separately and added together to get the length. The
formula shown in Table 2.2.8 may be used for calculating
the height for the age or alternatively the increase in height
is as shown in Table 2.2.9 may be used for calculating the
expected height. To make out short stature or dwarfism,
the McLarens classification (Table 2.2.12) may be used.
While measuring the height, it is also important to
measure the upper segment (from the vertex to the pubic
symphysis) and the lower segment (from the pubic
symphysis to the sole of the foot). The rate of growth of
the upper and lower segments varies with age as shown
in Table 2.2.10. Hence, any difference in the proportion
expected for that age may suggest the presence of specific
TABLE 2.2.9: Rate of increase in height in children
Ages

Height

At birth

50 cm

6 months

+ 12 cm (62 cm)

1 year

75 cm

2 years

85 cm (86 to 87 cm)

2 to 5 years

6 to 8 cm/year

5 years and above

5 cm/year

TABLE 2.2.10: Normal upper segment: lower segment ratio

in children
Ages
At birth
3 to 4 years
9 years
18 years

Upper segment
Lower segment
1.8
1
1.3
1
1
1
0.9
1

36 IAP Textbook of Pediatrics

TABLE 2.2.11: Conditions with altered upper segment:
lower segment ratio
Upper segment:
Lower segment ratio

Probable disorder

Proportionate
(normal ratio for age)

Delayed adolescence, hypopituitarism, constitutional

dwarfism, nutritional dwarf
Hypothyroidism, chondrodystrophy, achondroplasia,
Ellis-van Creveld syndrome,
Turners syndrome
Hurlers syndrome, Morquios
syndrome, hypogonadism

High ratio
(upper segment > lower
segment)
Low ratio
(upper segment < lower
segment)

Figure 2.2.7: Method of measuring head circumference

TABLE 2.2.12: McLarens classification for interpreting

height for corresponding age
Height for age

Interpretation

>105%
93 to 105%
80 to 93%
<80%

Giant
Normal
Short
Dwarf

growth disorders (Table 2.2.11). Stature should also be

defined with parents height being taken into account,
referred to as the mid-parental height.
For girls: Approximate projected adult height (in cm)
=

[Mothers height + (Fathers height 13)]

_________________________________________________

For boys: Approximate projected adults height (in cm)

=

[(Mothers height + 13) + Fathers height]

_________________________________________________

be calculated from Tables 2.2.13 and 2.2.14. The adult head

size is reached between 5 to 6 years. Microcephaly is
defined as head circumference, more than 3 standard
deviations below the mean or less than the 5th percentile
for the age and sex. Head size more than the 95th percentile
for age suggests macrocephaly.
Chest Circumference
This is measured at the level of the nipples (Fig. 2.2.8). In
the infant, the chest circumference is lesser than the head
cicumference by about 2.5 cm, and the two become equal
by one year after which the chest circumference exceeds
the head circumference. In undernutrition, the chest
circumference remains lower than the head circumference
TABLE 2.2.13: Head circumference growth velocity
Ages

Head circumference
growth velocity

Till 3 months

2 cm/month

3 months to 1 year

2 cm/3 months
(1/3rd of initial velocity)

1 to 3 years

1 cm/6 months
(1/12th of initial velocity)

3 to 5 years

1 cm/year
(1/24th of initial velocity)

Head Circumference
The size of the head is a good indicator of the size of its
contents, i.e. viz., the brain and the ventricles. Any
abnormality in the head circumference should alert the
doctor towards any problem with the brain or its related
structures. Head circumference is measured with a nonstretchable tape passing through the maximum point of
the external occipital protuberance posteriorly and a point
just above the glabella anteriorly as shown in Figure 2.2.7.
The head circumference at birth varies from 32 to 35 cm at
one year, from 43 to 46 cm and from 48 to 51 cm at five
years. The expected head circumference for the age may

TABLE 2.2.14: Formula for estimating head

circumference in the first year (after Dine et al)
Normal range of head circumference in cm (5th to 95th percentile)
(length in cm + 9.5) + 2.5
__________________________________

History Elicitation and Physical Examination

37

measuring midarm circumference (MAC) in the

community and has color bands. Green color indicates
MAC is > 13.5 cm, yellow color a MAC between 13.5-12.5
cm and red colour a MAC < 12.5 cm.
Arm Span

Figure 2.2.8: Method of measuring the chest circumference

It is the distance between the tips of the middle fingers

with both arms held wide open, i.e. spread apart. Normally, in young children it is 1 to 2 cm less than the length/
height. It equals the height at 10 years, and after 10 years
it is 1 to 2 cm more than the height. Increased arm span is
seen in Marfans syndrome and homocystinuria.

even beyond one and half years whereas in well-nourished

children, the chest circumference may exceed the head
circumference even before one year.

Weight for Height (WFH)

Midarm Circumference

Values above 90 percent are normal, while values below

90 percent indicate malnutrition and values above 120
percent indicate overweight.

The midarm circumference is taken as the name suggests,

at the midpoint of between the acromion and the olecranon
with the arm hanging by the side of the body (Fig. 2.2.9). It
is useful to detect malnutrition in young children (1-4
years). Values more than 13.5 cm may be considered
normal, while values less than 12.5 cm indicate significant
wasting and undernutrition. Shakirs tape is used for

This is calculated as shown below (WFH):

WFH = (weight of child weight corresponding
to height of child) 100

Body Mass Index (BMI)

It is calculated as:
Body mass index (BMI) =

weight in kg

________________________

(height in meter)2

BMI of 15-25 is considered normal, 25-30 is grade I

obesity, 30-40 is grade II and above 40 is grade III.
BMI = [weight height2] 100
Value less than 0.15 indicates malnutrition. This remains
constant up to 5 years of age.
Kanawati Index (KI)
This is useful in detecting protein energy malnutrition in
children between 4 months and 4 years. It is calculated as
follows:
KI = Midarm cicumference Head circumference
Interpretationnormal > 0.32, mild undernutrition 0.28
to 0.32, moderate undernutrition 0.25 to 0.28, severe
undernutrition < 0.25.
Growth Patterns
Figure 2.2.9: Method of measuring midarm circumference

See Table 2.2.15.

38 IAP Textbook of Pediatrics

TABLE 2.2.16: Primitive reflexes to be examined during
developmental assessment

TABLE 2.2.15: Growth patterns

Ages

Approximate
daily weight
gain (gm)

Growth in
Growth in head
length
circumference
(cm/month) (cm/month)

0-3 month

30

3.5

3-6 months

20

6-9 months

15

1.5

0.5

9-12 months

12

1.5

0.5

Reflexes

Age of appearance

Stepping

1-3 years

0.25

4-6 years

3 cm/year

1 cm/year

DEVELOPMENTAL EXAMINATION
Here, the developmental history obtained must be
confirmed by examining the child for the milestones
attained or lost. A large number of accepted methods are
available for assessing development. Of this, the Gessell
developmental scale and the Bayley developmental scale
are commonly used. The Baroda Developmental Screening
Tests and the Trivandrum Developmental Screening Chart
are useful for field assessment of chidrens development.
The development quotient (DQ) must be calculated
separately for motor and mental development.
Developmental age
DQ =
Chronological age

100

Developmental evaluation is of special value in

children with neurological diseases like neurodegenerative disorder and chromosomal anomalies like Downs
syndrome. It is also useful for following up children with
birth asphyxia or established cerebral palsy and mental
retardation. The common developmental/primitive
reflexes to be examined are shown in Table 2.2.16. The
absence of appearance of the primitive reflexes at the
expected time or their persistence beyond the time that
they should normally disappear should lead to a suspicion
of significant brain damage.

Birth

Age of disappearance
6 weeks

Placing

Birth

6 weeks

Moro

Birth

3 months

Sucking and

Birth

4 months while awake

Rooting

7 months while asleep

Palmar grasp

Birth

6 months

Plantar grasp

Birth

10 months

Tonic neck

2 months

4 to 6 months

Landau

3 months

24 months

Neck righting

4 months

24 months

Parachute

9 months

Persists

Sexual Maturity Rating

Sexual maturity rating in boys/girls is shown in
Table 2.2.17.
SYSTEMIC EXAMINATION
It is beyond the scope of this chapter to cover the
examination of every system in detail. Nevertheless it can
be obtained from a standard textbook of clinical
examination. Here we have attempted to give salient points
in clinical examination that are different in children as
compared to adults.
Respiratory System
Inspect the chest wall for any deformities. Costochondral
beading is seen in rickets (broad and dome-shaped), in
scurvy (sharp due to posterior subluxation of the sternum)
and in chondrodystrophy. Look for working of the
accessory muscles of respiration, i.e. flaring of alae nasi,
sternomastoid contraction, suprasternal, subcostal and
intercostal recession which indicate dyspnea. Observe for

TABLE 2.2.17: Sexual maturity rating in boys/girls

SMR stage

Pubic hair (boys/girls)

Breasts

Penises

Testes

Preadolescent

Preadolescent

Preadolescent

Preadolescent

Sparse, slightly pigmented

Breast and papilla elevated,

areolar diameter increased

Slight enlargement

Enlarged scrotum, pink

Darker, beginning to curl

Breast and areola enlarged,

no contour separation

Longer

Larger

Coarse, curly, abundant but

less than adult

Areola and papilla form

secondary mound

Larger

Larger, scrotum dark

Adult distribution, spreads to

medial surface of thighs

Mature, nipple projects

Adult size

Adult size

History Elicitation and Physical Examination

indrawing of the lower ribs (Harrisons sulcus) which
indicates chronic obstructive airway disease like bronchial
asthma. Vocal fremitus is rarely of value in young children.
Grunting respiration in a child indicates severe respiratory
disease. Percuss lightly in infants and small children, tap
the chest wall directly rather than using another
pleximeter finger. Due to the thin chest wall, the chest is
more resonant than adults. Before starting to auscultate,
allow the child to play with your stethoscope, to allay its
fears. Often it is less threatening to examine the back of the
chest first. Due to the thin chest wall, breath sounds are
louder in children than in adults and their character is
more like the bronchial breathing of adults. This is called
puerile breathing. Do not be disheartened with a crying
child, as breath sounds can be auscultated better in them.
Be careful to distinguish the conducted sounds from the
upper respiratory tract as in laryngomalacia, upper respiratory tract infection, etc.
Cardiovascular System
In a neonate the apical impulse is located slightly outside
the midclavicular line in the 4th intercostal space. By 2
years, it comes to the midclavicular line in the 4th
intercostal space and comes to the adult position, i.e. 5th
intercostal space 1 cm medial to the midclavicular line
between 4 to 7 years. In infants the right ventricles are
dominant as compared to adults (where left ventricle is
dominant). Due to the short neck of infants and young
children, it is difficult to see the jugular venous pulse and
pressure. Use a pediatric stethoscope with a small
diaphragm to auscultate, as the intercostal spaces are
narrow. It is preferable to auscultate the heart while the
infant is comfortably sleeping or feeding from the mother.
It is easier to hear the normal splitting of the heart sounds
and P2 is louder in young children, i.e. < 5 years.
Functional systolic flow murmurs and venous hum are
often heard in normal children.
Abdomen
The best place to examine the childs abdomen is the
mothers lap, preferably while the child is feeding. Even if
the child is struggling, it may be put on the mothers
shoulder and the abdomen is palpated from behind by
ballottment, i.e. palpation just when the child breathes
and the abdomen relaxes. Unlike in adults, it is not
necessary to fold the legs of the child while palpating the
abdomen. Young children normally have a protuberant
abdomen. Look for umbilical (which may be normally seen
in infants) and inguinal hernia. The liver is normally

39

palpable in children till the age of 4 years, i.e. up to 2 cm

below the costal margin. In view of this it is necessary to
measure the span of the liver in order to make out actual
enlargement. It is carried out by percussing the upper
margin of dullness and by palpating the lower edge of the
liver in the mid-clavicular line. The liver span ranges from
about 4.5 to 5 cm at 1 week of age to approximately 7 to 8
cm in males and 6 to 6.5 cm in females by 12 years of age.
The spleen may be normally palpable in infants up to 2 to
3 months. Examine the genitalia for intersex, phimosis,
undescended testis, hypospadiasis or epispadiasis. The
anus is examined for anal excoriation and pinworms.
Nervous System
Neurological examination of the young child is quite
difficult, especially sensory examination and requires
ingenuity on the part of the doctor to get the childs
cooperation. Developmental screening and assessing of
the primitive reflexes should be carried out as already
mentioned. Much information regarding the neurological
status of the child can be learnt by just observing the child,
as the history is being elicited. Coordination is best tested
by watching the child, play. Orientation is best tested only
in children above 4 to 5 years. Handedness becomes
apparent at about 3 years of age. Signs of meningeal
irritation, i.e. neck stiffness, Kernigs sign, Brudzinskis
sign must be looked for. They may not be present in infants
and in the presence of severe undernutrition or overwhelming sepsis. Fundus may be normally pale in infants.
Lifting the child gives a good idea about the muscle tone.
If it is hypotonic the child will slip through the hands.
The plantar reflex may be extensor up to 1 year of age. But
persistence of extensor plantar beyond 2 years, is definitely
pathological. Tendon reflexes in young infants tend to be
brisk. The deep tendon reflexes may be diagrammatically
represented as shown in Figure 2.2.10, using the notations
shown below.
0
+
++
+++
++++

= absent
= sluggish
= normal
= brisk
= exaggerated

History taking and clinical skill development in pediatrics are therefore to be learnt by repeated exposure to case
interviews and hands on training, in examination. The
more a student gets this type of exposure, the more he can
engage himself in self-analysis, which will help him to
carryout the clinical examination thoroughly.

40 IAP Textbook of Pediatrics

THE PRACTICE OF DIFFERENTIAL DIAGNOSIS

Figure 2.2.10: Diagrammatic recording of

deep tendon jerks

During situations when the diagnosis of the child is not

very clear (which may be the case quite often), it becomes
necessary to make a set of most probable diagnoses. This
is called differential diagnosis. This should be based on
the history, clinical symptoms and clinical signs that have
been elicited. The differential diagnoses thus made will
help us to plan out investigations towards proving or
disproving each probable cause. Hence, to be of practical
value the list should be as short as possible and should
only include conditions that could reasonably explain
most of the child's history, symptoms and signs. The list
should be given in descending order of probability of the
various likely diagnoses, based on the positive and
negative points towards each.

2.3 Parent Counseling

Parang N Mehta

Once upon a time, parents would bring their sick child to

a doctor, and be happy to leave with a prescription.
Explanations, empathy, and politeness were never
expected of doctors.
Times have changed, however, and so have our patients
and their parents. In todays scenario, patients are health
care consumers, we are providers, and the traditional
doctor-patient relationship has changed. Patients and
parents today demand information, courtesy and time.
Arrogance, taciturnity, and a generalised lack of
communication skills are no longer acceptable to health
care consumers.
Apart from the demands of patients, good communication is good medicine. It enhances patients understanding and adherence to therapy, and has a therapeutic
effect. If the parents do not understand the disease and
treatment issues well, they may not adhere to therapy,
resulting in poor outcome. It is important for doctors to be
good communicators, and most medical colleges in USA
now teach and assess communication skills. In our

country, however, this essential component of a doctors

skill set is largely neglected.
COMMUNICATION SKILLS
These are, quite simply, the skills that allow human beings
to communicate with each other in an effective way. For
pediatricians, communication skills consist of:
i. The ability to talk with parents. Not to parents, not at
parents, but with them. Listening is an essential part;
communication must be a two-way process.
ii. The ability to communicate sufficiently well with patients
and parents so as to understand their concerns,
problems, and beliefs, and to elicit relevant
information.
iii. The ability to explain the childs illness and its treatment.
The explanation should be clear, complete, and in a
language that the parents can easily understand. The
treatment options should be explained clearly and
completely, so that they can make informed
decisions about treatment.

History Elicitation and Physical Examination

iv. The ability to convince parents to follow a treatment
plan. This is especially important when embarking
on prolonged, expensive, difficult, or culturally
unacceptable treatment for a child.
v. The ability to establish a relationship with the parents
and child, based on mutual respect and trust.
vi. Soft skills like being able to put all classes of parents
at their ease, being able to generate confidence, and
being comfortable holding conversations on nonmedical subjects with parents and patients. In days
of old, these were the components of a good
bedside manner, which was considered an
important attribute of a successful practitioner.
THE IMPORTANCE OF COMMUNICATION SKILLS
There are several advantages to possessing good
communication skills (Table 2.3.1). In general, a doctor
with these skills is more likely to have happy, satisfied
patients, than an equally technically competent doctor
who does not bother about communication. Even if a
pediatricians diagnosis and treatment are accurate,
thoroughly rational and successful, poor communication
leaves parents unhappy and resentful. On the other hand,
answering all questions without hesitation enhances
patients and parents belief in a doctors expertise. This
is especially so with chronic or incurable diseases, which
are associated with anxiety, stress, and uncertainty for
the whole family.A doctor who offers support, empathy,
and clear and complete explanations at every step can
help alleviate these to a significant extent. Good
communication also enhances adherence to long-term
therapy. On the other hand, lack of communication can
lead to treatment discontinuation and therapeutic failure.
This can extend to depression and despair, or to anger
and complaints.
Most complaints in health care systems, both public
and private, arise from poor communication. Very few
people can judge the quality of a doctors examination,
diagnosis, or prescription. Obviously, relatively few
complaints originate in poor performance in these areas.
TABLE 2.3.1: Advantages of good communications

Patient satisfaction, leading to regular visits and referrals.

Feeling of empowerment and control.
Adherence to treatment plans.
Loyalty even if treatment is not immediately effective.
Less chances of complaints and legal action in the event of
a mistake.

41

TABLE 2.3.2: What patients want

Clarity and directness.

Listening.
Honesty.
More and better information about their illness, treatment
plan, and expected outcome.
More openness about the hazards and side-effects of
treatment.
More information about the relief of symptoms and other
concerns.
Advice on what they can do to help themselves.
Information on other treatments available.
A supportive, non-judgmental, empathetic doctor.

Parents are angered by the doctors refusal to spend time

with them, refusal to give complete and clear explanations, a casual or callous approach to the childs problems,
and a lack of courtesy and care. When all these are followed
by a poor treatment outcome, complaints, quarrels, and
legal action are likely. On the other hand, good
communication can play a significant part in avoiding
complaints and malpractice claims.
BARRIERS TO GOOD COMMUNICATION
Traditionally, we have not paid much attention to
communicating well. Even today, few of us appreciate the
importance of communication skills, and hardly any make
a concerted effort to learn and apply such skills. This is
perhaps the single biggest barrier to good communication.
Unless we accept the contribution of good communication
to patient outcomes and parent satisfaction, poor communication is likely to remain the norm in the medical field.
Even doctors who realise the importance of good
communication are not always successful at implementing it. Many of us do not realise what patients want from
us (Table 2.3.2). Some other barriers to good communication are:
Lack of time: Most pediatricians see a large number of
patients every working day. This is true of both
government and private hospitals. History taking,
physical examination, and prescription writing are of
course, essential parts of a clinical encounter. When time
is short, it is the communication with parents that is
sacrificed. We can overcome this, partially, by deputing
some explanations to paramedical staff.
Arrogance: Arrogance is deeply ingrained into doctors. We
expect our patients and their parents to follow our
commands unquestioningly. We do not understand the
need for explanations, and often give none.

42 IAP Textbook of Pediatrics

Shyness: The parents may be very shy and not ask the
questions they have in their minds. On the other hand, the
doctor may be shy, and either ignore questions, or give
minimal and incomplete answers. Shyness on either side
stands in the way of adequate information being imparted.

ii. Expected progress of the child during treatment.

iii. What to expect by way of improvement, side effects,
fresh problems, etc.
iv. Chances of complete cure.
v. Treatment options.

Language and jargon: In any major city of India, there is

likely to be a large population of people from other states
and linguistic groups. Communication with them can be
a problem, and needs a special effort.
Most such people will bring an interpreter with them
when coming to us. However, we must use such a person
well. It is necessary to give the interpreter the information
in small chunk, and have him translate it for the parents
as you go along. This is especially important with the
prescriptionexplain one drug at a time and have him
translate.
A major problem occurs when the parents speak
English. As soon as we meet an English speaking parent,
we start speaking in technical/medical language. This
leaves the parents confused and uninformed. When
talking in English, it is essential to make an effort to talk in
language that a non-medical person can understand.

The last point is especially important. Complementary and alternative medicine is a growing business, and
their remedies are often advertised and promoted
aggressively. Dismissing them off hand does not convince
parents. It is necessary to explain treatment goals, explain
how our treatment works, and convey to them the
unscientific basis and unreliability of advertised magic
remedies.

Deafness: Deafness is a major cause of poor communication,

and is a special concern when our patients are accompanied by their grandparents. When we suspect a hearing
impairment, we must speak loudly, slowly and distinctly.
Other useful measures are: voice amplification, if a devide
is available; a quiet room, to improve signal to voice ratio;
use of written communication; and asking the family, at
the end of the consultation, if they have understood
everything, and if they have any questions.
An important measure is to have the relatives repeat
the prescription instructions, to ascertain they have been
understood. This ensured that the child will receive the
medication as it has been prescribed.
Phones: Earliers, a telephone would buzz discreetly on
a receptionists desk, and a consultation would not be
interrupted. Today, theres a phone in everyones pocket
or hand, and calls can interrupt and hinder communication terribly.
INFORMATION NEEDS
When faced with a chronic/permanent condition, most
parents want to know:
i. What treatment can achieve for their childrelief of
symptoms, prolongation of life, shortening of the
course of the disease, etc.

STRATEGIES FOR IMPROVING COMMUNICATION

Check what the parents know: With intelligent and
knowledgeable parents, the discussion can begin at a
higher level. However, assessing the parents knowledge
is important, because some of their knowledge or
understanding may be faulty. Many parents get their
knowledge from magazines, lay books, and websites. Most
of these sources have no system of review or control of the
information published.
Assess what the parents want to know: Some parents want to
know every little fact and detail about their childs
condition. Others simply want a prescription and an
assurance that all will be well. It is important to assess the
parents desires, and communicate accordingly.
Assess understanding: The parents may not fully understand
what is being told to them. They are upset about the child
being sick, they have poor comprehensive skills, they have
language problemsthere could be many reasons. If the
parents indicate that they are not fully understanding
what is being told to them, stopping the explanations for
that session might be appropriate and take it up next time.
Understanding can be improved by giving time to absorb,
and by repetition. At the end of the consultation, the
parents can be asked to repeat some information, to ensure
it has been understood.
Listening skills: Most of us hardly allow the parents to speak.
As soon as they start their description of the childs
problem, we start asking questions, and attempt to keep
the consultation focussed. However, this often leads to an
incomplete description of the childs problems.
Listening well is an essential part of communication.
This requires the provision of adequate time and patience,
and the willingness to listen to parents concern. A quiet

History Elicitation and Physical Examination

43

TABLE 2.3.3: Dos and Donts of communication

Do

Dont

Greet the child and parent by name.

Smile.
Sit down when talking.
Try to talk in the patients language.
Direct the conversation to relevant directions.
At the end of the consultation, ask if the parents have
any questions.
Engage the parents in a dialogue.
Give time for the parents to absorb and understand the
content of your explanations, then to ask questions.

room, lack of interruptions, provision of chairs for the

parents, sitting at an appropriate distance, good eye
contact, etc. are helpful to enhance listening and learning
from the parents.
Build confidence: The parents confidence must be bolstered.
We need to accept what the parents say, without judging
it. A little specific praise for the parents efforts so far helps
significantly in building confidence and helping parents
to cope. Some suggestions for future care improve their
confidence that they will be able to manage the situation.
Giving false hope is wrong, but we can give information
in a positive manner.
Truth: Parents like to know the truth, but the bald truth
can be harsh and shocking. Parents deserve to know the
truth, but its delivery should be tempered with commonsense and empathy. If the facts are particularly unpleasant,
they can be delivered in small parts spread out over two
or more visits. However, if parents express a desire to know
everything, it must be told to them. Withholding
information leads to distrust.
Simplicity and clarity: Not all parents have a good
educational and intelligence level. Explaining things in
simple, clear, and direct language is very important. Clarity
and directness are particularly important with parents of
low comprehension abilities. Many people do not
comprehend words like growth and tumor, for
example. Cancer sounds shocking, but may be
necessary to drive home the problem to parents.
Be tolerant: Parents react in various ways, and we should
be prepared. Blame, anger, a sudden outpouring of grief
all these are common reactions. We should be ready to
deal with these emotions with understanding and
support.

Look at your watch frequently.

Appear to be in a hurry.
Use too many medical terms.
Talk with your hand on the door handle, or foot outside
the door.
Interrupt all the time.
Start examination and then write out a prescription
before the main problem has been identified.
Give long lectures as explanation.
Ignore concerns mentioned by parents.

Empathy: Parents of sick children are going through a

difficult experience. They appreciate the fact that their
doctor understands their situation and their difficulties.
While sympathy has overtones of pity and is likely to be
resented, empathy is simply an understanding of the
parents plight.
Apart from these broad principles, many small
factors affect communication positively or negatively
(Table 2.3.3).
KEY POINTS

Communication skills contribute to good medical care and

patient satisfaction.
Communication skills contribute to a doctors respect, a
patients faith, and adherence to treatment.
Doctors with good communication skills have better clinical
and commercial success, less stress, and more job
satisfaction.

CONCLUSION
Good communication is an art that is so far acquired,
developed and improved by experience. However, it can
also be taught, and assessed, by means of structured
programs. Medical students will gradually have
increasing levels of training in this essential aspect of
medicine. Though formal training is not easily available
to doctors in jobs or practice, we can improve our
communication skills with some personal efforts. This will
lead to better patient/ parent satisfaction and perhaps
better clinical outcomes. Compassion, explanation, and
reassur-ance are valued by our patients and their families
as much as a diagnosis, treatment, and cure.
ACKNOWLEDGEMENT
The article has been reporduced from Indian Pediatrics with
permission from the Editor-in-Chief.

44 IAP Textbook of Pediatrics

BIBLIOGRAPHY
Bartel DA, Engler AJ, Natale JE, Misra V, Lewin AB, Joseph
JG. Working with families of suddenly and critically ill
children. Arch Ped Adolesc Med 2000;154: 1127-33.
2. Bull SA, Hu XH, Hunkeler EM, Lee JY, Ming EE, Markson
LE, et al. Discontinuation of use and switching of
antidepressants: Influence of patient physician
communication. JAMA 2002;288:1403-9.
3. Fook L, Morgan R, Sharma P, Adekoke A, Turnbull CJ.
The impact of hearing on communication. Postgrad Med
J 2000;76:92-5.
4. Langewitz WA, Eich P, Kiss A, Wossmer B. Improving
communication skills: a randomized controlled
behaviorally oriented intervention study for residents in
internal medicine. Psychosom Med 1998;60:268-76.

5.

1.

6.
7.

8.
9.

Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel

RM. Physician patient communication. The relationship
with malpractice claims among primary care physicians
and surgeons. JAMA 1997;277:553-9.
Meryn S. Improving doctor patient communication. Br
Med J 1998;316:1922-30.
Moore PJ, Adler NE, Robertson PA. Medical malpractice:
the effect of doctor patient relations on medical patient
perceptions and malpractice intentions. West J Med 2000;
173:244-50.
Partridge MR, Hill SR. Enhancing care for people with
asthma: the role of communication, education, training
and self management. Eur Resp J 2000;16:333-48.
Yedidia MJ, Gillespie CC, Kachur E, Schwartz MD, Ockene
J, Chepaitis AE, et al. Effect of communication training
on medical student performance. JAMA 2003; 290:115765.

3.1 Neonatal Nomenclature and Definitions: Meharban Singh, Vinod K Paul ........................................................................................... 46
3.2 Resuscitation of an Asphyxiated Newborn Baby: Meharban Singh, Ashok K Deorari ....................................................................... 50
3.3 Care of a Normal Newborn Baby: Meharban Singh, Ashok K Deorari .................................................................................................. 56
3.4 Common Developmental and Physiological Problems in Newborn Babies: Meharban Singh, Vinod K Paul ................................. 61
3.5 Management of Low Birth Weight Babies: Vinod K Paul, Ashok K Deorari, Meharban Singh ............................................................ 65
3.6 Common Diseases of Newborn Babies: Meharban Singh, Vinod K Paul, Ashok K Deorari ................................................................ 71

46 IAP Textbook of Pediatrics

3.1 Neonatal Nomenclature and Definitions

Meharban Singh, Vinod K Paul
It is essential to have uniformly accepted definitions to
express perinatal-neonatal morbidity and mortality for
ease of comparison with other national and international
studies. The adoption of standard nomenclature is
essential for generating meaningful data and for surveillance of impact of interventional strategies. The majority
of definitions and terminologies described below are
based on the standard sources such as tenth revision of
International classification of diseases (ICD) by WHO and
are duly approved and adapted by the Task Force of
National Neonatology Forum of India.
Fetus
Fetus is a product of conception, irrespective of the
duration of pregnancy, which is not completely expelled or extracted from its mother. Up to 9 weeks of
gestation, it is designated as embryo.
Live Birth
Live birth is defined as complete expulsion or extraction
from the mother of a product of conception (irrespective
of the duration of pregnancy) and which after such
separation, breathes or shows any other evidence of life
such as beating of the heart, pulsation of umbilical cord
or definite movements of the voluntary muscles
irrespective of the attachment of placenta and/or cord.
In 1970, WHO recommended that babies weighing
less than 500 g at birth should show signs of life for at
least one hour before they are designated as live born.
Fetal Death
Death prior to the complete expulsion or extraction from
its mother of a product of conception irrespective of the
duration of pregnancy, the death is indicated by absence
of any signs of life.
Early fetal death Death at a gestational age of less than
22 weeks or of a fetus weighing less than 500 g or crownheel length (CHL) of less than 25 cm.
Intermediate fetal death Death at a gestational age of 22
to 27 weeks or of a fetus weighing 500 to 999 g or CHL
between 25 cm to less than 35 cm.

Late fetal death Death at a gestational age of 28 weeks or

more of a fetus weighing 1000 g or more or CHL of at
least 35 cm. The body may be fresh or macerated.
Early fetal deaths are called abortions, while intermediate and late fetal deaths are designated as stillbirths.
Birth Weight
Birth weight is the first weight of a live or stillborn baby
which should preferably be taken within the first hour
of life and certainly during the first day of life before any
significant postnatal weight loss has occurred. If weight
is recorded after 24 hours, the age at which weight is
taken should be specified.
Birth Weight Groups
Low birth weight (LBW) babies Babies with a birth weight
of less than 2500 g (up to and including 2499 g)
irrespective of the period of gestation. These include
preterm (one-third) and small-for-dates term (two-thirds)
babies. In India, for purposes of according specialized
care, babies with a birth weight of less than 2000 g are
considered as high-risk and are admitted to the special
care neonatal unit (SCNU).
Very low birth weight (VLBW) babies Babies with a birth
weight of less than 1500 g (up to and including 1499 g).
Extremely low birth weight (ELBW) babies Babies with a
birth weight of less than 1000 g (up to and including
999 g).
Gestational Age
Gestational age is calculated from the first day of the last
normal menstrual period till the date of birth and is
expressed in completed weeks, e.g. 34 weeks + 6 days
are considered 34 weeks only.
Gestational Age Groups
Preterm (Immature, born early, "premature") Preterm is
defined as a baby with a gestation of less than 37 completed weeks, (up to 36 weeks or less than 259 days).
Term Babies with a gestational age between 37 to 41
weeks are called as term babies (259-293 days).

Newborn Care
Post-term (postmature) Babies with a gestational age of
42 weeks or more are classified as post-term babies (294
days or more).
Classification by Birth Weight and
Gestational Age Groups
Small-for-dates (SFD) babies (Small-for-gestational age, lightfor-dates, intrauterine growth retardation) Babies with a birth
weight of less than tenth percentile for their gestational
age are designated as SFD babies (Fig. 3.1.1). For purposes
of specialized care and monitoring of blood glucose
levels, babies with a birth weight of less than third
percentile for the period of their gestation are admitted
in the special care nursery unit (SCNU). Dysmaturity
refers to the characteristic marasmic appearance of a baby
reflecting placental dysfunction. This term should
preferably be avoided.
Ideally, regional intrauterine growth charts should
be constructed from a population of high socioeconomic
level with optimal maternal nutrition, and after
excluding known maternal and fetal conditions, which
cause intrauterine growth retardation (IUGR). It also
appears justified to employ one universally accepted
international reference standard for purposes of
comparison of the data.

47

Appropriate-for-dates (AFD) babies (Appropriate-forgestational age) Babies with a birth weight between 10th
to 90th percentile for the period of their gestation.
Large-for-dates (LFD) babies (Large-for-gestational age, heavyfor-dates) Babies with a birth weight of more than
ninetieth percentile for the period of their gestational age.
The babies with a birth weight of more than 97 percentile
for their gestation are considered high-risk and
monitoring for hypoglycemia.
By combining classification of the babies on the basis
of gestational age alone and gestational age with birth
weight, the newborn population can be divided into the
following 9 subgroups.
1. Preterm
I. SFD
II. AFD
III. LFD
2. Term
I. SFD
II. AFD
III. LFD
3. Post-term
I. SFD
II. AFD
III. LFD
The neonatal mortality is high among preterm babies
due to anatomical and functional immaturity of various
body organs. The least neonatal mortality is seen in term
appropriate-for-dates babies. In each gestational group
(whether preterm, term or post-term) mortality is higher
among LFD and SFD babies as compared to AFD babies.
Perinatal Period
Perinatal period extends from the twenty-eighth week
of gestation (or more than 1000 g) to the seventh day of
life (early neonatal).
PMR =

Total perinatal deaths

__________________________________

Total number of births

Extended PMR =
Intermediate Late

1000

Early

stillbirths + stillbirths + neonatal deaths 1000

_____________________________________________________________

Total number of births

Figure 3.1.1: Intrauterine growth curve. This helps in classifying neonates into three categories, viz. small-for-dates (SFD),
appropriate-for-dates (AFD) and large-for-dates (LFD)

In view of the increasing survival of the babies

weighing less than 1000 g as a result of improvements in
the perinatal care, the concept of extended perinatal

48 IAP Textbook of Pediatrics

period has been introduced. This period extends from
twenty-second week of gestation (or more than 500 g) to
7th day of life.
Perinatal Mortality Rate (PMR)
Perinatal mortality rate (PMR) is defined as late fetal plus
early neonatal (first week) deaths of babies weighing
more than 1000 g (or 28th week of gestation or more) at
birth per 1000 total births weighing over 1000 g. It is
suggested that for international comparisons, the
numerator as well as the denominator in perinatalneonatal statistics should be restricted to fetuses and
infants weighing 1000 g or more.
Neonatal Period
Neonatal period extends up to 28 days of life. Infant up
to 28 days of life is called a newborn baby or neonate.
Early neonatal period refers to first 7 days or 168 hours
of life, while late neonatal period signifies period from
7 days to under 28 completed days of life.
Neonatal Deaths
First day death is defined as deaths occurring within 24
hours of age (exclude if baby had completed 24 hours of
age).
Early neonatal deaths include deaths within 168 hours
of age (exclude if baby had completed 168 hours of age).
Neonatal deaths include all deaths within 28 days of
age.
Neonatal Mortality Rate (NMR)
Early NMR Neonatal deaths of babies weighing over
1000 g during first 7 days per 1000 live births.
Late NMR or unspecified NMR Neonatal deaths of babies
weighing over 1000 g during 28 days of life per 1000 live
births.
The extended neonatal mortality rate can be calculated by including babies weighing up to 500 g. It is
suggested that the hospital-based neonatal-perinatal
statistics may be presented separately for booked and
unbooked cases.
Birth Weight Classification for
Perinatal-neonatal Data
The morbidity and mortality can be expressed by weight
intervals of 500 g, i.e. 1000 to 1499 g, 1500 to 1999 g, 2000
to 2499 g and so on.

Gestational Age Classification for

Perinatal-neonatal Data

Less than 28 weeks (less than 196 days)

2831 weeks (196223 days)
3236 weeks (224258 days)
3741 weeks (259293 days)
42 weeks and more (294 days and more)

Calculation of Incidence
The incidence of neonatal conditions (e.g. LBW babies,
preterm and birth asphyxia, etc.) should be calculated
per 100 live births, while that of pregnancy and labor
related conditions (e.g. toxemia, maternal anemia,
cesarean deliveries, etc.) should be calculated per 100
total births.
Maternal Mortality
The maternal death is defined as a death of a woman
known to be pregnant within 42 days of termination of
pregnancy, irrespective of the duration or site of the
pregnancy. The death may be due to any cause related
to or aggravated by the pregnancy or its management
but not from accidental or incidental causes. The maternal
mortality rate is expressed as maternal deaths per 1000
live births.
Direct obstetric death Death resulting from complications
of pregnancy, childbirth or puerperium including
interventions, omissions, incorrect treatment or from a
chain of events resulting from any of the above causes.
Indirect obstetric death Death resulting from previous
existing disease or a disease that developed during pregnancy, childbirth or the puerperium which was not due
to direct obstetric causes, but which was aggravated by
physiologic effects of pregnancy.
Clinicopathological Classification of
Perinatal Deaths
There is a lack of unanimity and considerable confusion
exists regarding the most acceptable method for classification of deaths during perinatal period. It is essential
that all perinatal centers should adopt an identical or
uniform protocol for clinicopathological classification of
perinatal deaths so that mortality data is comparable in
order to identify any regional differences. During
perinatal period, many deaths cannot be classified merely
on the basis of clinical findings unless it is complemented

Newborn Care
by autopsy data. Efforts should always be made to obtain
an autopsy in each and every case of perinatal death. It
is generally easier to obtain permission for autopsy in a
case of perinatal death due to relatively less emotional
bondage of parents and their concern for having a normal
healthy baby during next pregnancy. A routine autopsy
performed by an adult-oriented pathologist may not be
informative and may be unable to identify the cause of
death.
Neonatal and Perinatal Mortality
When NMR was 70 per 1000 live births (Fig. 3.1.2), it
contributed to 63 percent of infant mortality rate (IMR
of 110 per 1000 live births). The current NMR is 39 per
1000 live births and the current IMR is 57 per 1000 live
births at the national level (Table 3.1.1). The most
important causes of NMR are bacterial infections (sepsis,
pneumonia), LBW and birth asphyxia. Congenital
malformations also contribute to neonatal deaths to a
small extent. Tetanus neonatorum which was the single
most important cause of neonatal deaths until a few years
ago has now been virtually eradicated. This is responsible
for the decline of neonatal mortality from 70 per 1000
live births in 1981 to the current level.
Neonatal Mortality in Different States
India is an immense country with a wide range of
neonatal mortality rates in different states, from as low
as 1.3 per 1,000 live births in Kerala to around 51 in
Chattisgarh and 48.6 in Jharkhand (Table 3.1.1). ENMR
and late neonatal mortality rates (LNMR) together make
up the NMR.

49

TABLE 3.1.1: Neonatal and infant mortality rates by state

State

Neonatal
mortality

Postneonatal Infant
mortality
mortality
(PNM)
(IMR)

India

39.0

18.0

57.0

North
Delhi
Haryana
Himachal Pradesh
Jammu & Kashmir
Punjab
Rajasthan
Uttaranchal

29.3
23.6
27.3
29.8
28.0
43.9
27.6

10.5
18.1
8.9
14.9
13.7
21.4
14.3

39.8
41.7
36.1
44.7
41.7
65.3
41.9

Central
Chhattisgarh
Madhya Pradesh
Uttar Pradesh

51.1
44.9
47.6

19.7
24.7
25.0

70.8
69.5
72.7

East
Bihar
Jharkhand
Orissa
West Bengal

39.8
48.6
45.4
37.6

21.9
20.2
19.3
10.4

61.7
68.7
64.7
48.0

Northeast
Arunachal Pradesh
Assam
Manipur
Meghalaya
Mizoram
Nagaland
Sikkim
Tripura

34.0
45.5
18.7
23.6
16.3
19.8
19.4
33.1

26.7
20.6
11.1
21.0
17.7
18.5
14.3
18.3

60.7
66.1
29.7
44.6
34.1
38.3
33.7
51.5

West
Goa
Gujarat
Maharashtra

8.8
33.5
31.8

6.5
16.2
5.7

15.3
49.7
37.5

South
Andhra Pradesh
Karnataka
Kerala
Tamil Nadu

40.3
28.9
11.5
19.1

13.2
14.3
3.8
11.2

53.5
43.2
15.3
30.4

Common Causes of Perinatal Deaths

Figure 3.1.2: Infant mortality in India, with changes in neonatal

(black bar) and postneonatal (white bar) mortality rates per
1000 live births

Perinatal deaths include late fetal and early neonatal (first

week) deaths. Perinatal mortality rate in India is around
8.5 per 1000 live births. There is almost equal contribution
by stillbirths and early neonatal deaths. A large majority
of stillbirths are attributable to placental insufficiency due
to pregnancy-induced hypertension (PIH) and maternal
malnutrition, fetal and intranatal hypoxia, antepartum
hemorrhage and congenital malformations.

50 IAP Textbook of Pediatrics

Nearly one-half of early neonatal deaths occur
during first 24 hours of life. Neonatal mortality is
directly related to birth weight and gestational maturity
of the infant. In India it varies between 0.5 percent
among healthy term infants to about 30 percent in
preterm or infants with a birth weight of less than 2000
g. It is estimated that about 30 to 40 percent infants born
in India are LBW (<2500 g at birth), and about 85 percent
of all neonatal deaths occur among them. The neonatal
mortality of LBW babies is about 20 times of mortality
among term-AGA infants. Generally, several factors
operate in most perinatal deaths. Placental insufficiency,
premature separation of placenta and obstetrical
difficulties are important predisposing factors. Bacterial
infections and septicemia account for one-fifth of all
neonatal deaths.

REFERENCE
1.

National Family Health Survey (NFHS-3), 2005-06.

Ministry of Health and Family Welfare www.nfhsindia.
org accessed on 14th June, 2008.

BIBLIOGRAPHY
1. Singh M, Deorari AK, Khajuria RC, et al. A four-year
study on neonatal morbidity in a New Delhi hospital.
Indian J Med Res 1991;94:186-92.
2. Singh M, Deorari AK, Khajuria RC, et al. Perinatal and
neonatal mortality in a hospital. Indian J Med Res
1991;94:1-5.
3. Singh M, Deorari AK, Paul VK, et al. Primary causes of
neonatal deaths in a tertiary care hospital in Delhian
autopsy study of 331 cases. Ann Trop Pediatr
1990;10:151-57.
4. Singh M, Paul VK. Standard nomenclature and definitions for expressing neonatal morbidity: A plea for
uniformity. Indian Pediatr 1989;26:1089-95.

3.2 Resuscitation of an Asphyxiated

Newborn Baby
Meharban Singh, Ashok K Deorari
Establishment of spontaneous breathing afterbirth is
most crucial for the survival of a newborn baby. Most
babies have a smooth transition from fetal to neonatal
life, and they are able to establish spontaneous breathing without any active assistance. Nevertheless, 4 to 6
percent of the neonates are likely to face difficulties in
initiating spontaneous breathing at birth and they require
active resuscitation. Perinatal hypoxia and birth asphyxia
are the leading cause of perinatal mortality in our
country. Apart from high perinatal mortality, birth
asphyxia is an important cause of neuromotor disability.
In order to improve survival of newborn babies due to
perinatal hypoxia and improve the quality of life, it is
essential that every birth is considered as a medical
emergency, and labor room area is adequately provided
with infrastructure and facilities for resuscitation of
newborn babies. Effective resuscitation demands availability of at least two persons, one who is actively resuscitating and the other who is monitoring the condition of
the baby and assisting the resuscitator for administration
of drugs and external cardiac massage when required.

Fetal Hypoxia
The existence of certain high-risk factors during pregnancy and labor may forewarn and alert the labor room
staff that they should be fully prepared to meet the
challenge of an asphyxiated baby (Table 3.2.1). All highrisk pregnancies should be monitored for fetal growth,
TABLE 3.2.1: Conditions demanding resuscitation alert
1. Fetal distress
2. Meconium-stained liquor
3. Placental insufficiency (PIH, hypertension, postmaturity)
4. Premature onset of labor
5. Antepartum hemorrhage
6. Malpresentation, difficult and abnormal or operative
delivery
7. Cord prolapse
8. Rhesus isoimmunization
9. Multiple gestation
10. Bad obstetric history

Newborn Care
presence of congenital malformations, adequacy of
placental function and evidences of fetal hypoxia.
Nonstress test, oxytocin challenge test and biophysical
profile score on ultrasound examination are useful to
identify early evidences of fetal hypoxia. The time
honored clinical parameters of fetal distress offer useful
guidelines to an experienced obstetrician. The asphyxiated fetus initially behaves like a strangulated individual
and makes violent efforts leading to exaggerated fetal
movements which is followed by reduced or absent fetal
movements. Due to the release of catecholamines,
initially there is tachycardia followed by bradycardia and
slow, irregular heart beats. The presence of meconium
due to visceral over activity in a baby presenting as vertex
is an important and ominous sign of fetal hypoxia
specially when associated with an abnormal fetal heart
pattern.
Pathophysiology of Asphyxia
Birth asphyxia is associated with reduction in arterial
oxygen tension, accumulation of carbon dioxide and fall
in blood pH. These biochemical changes lead to rightto-left shunt with the perpetuation of birth asphyxia.
During the early phase of birth asphyxia, the blood
glucose level is significantly elevated due to the
breakdown of glycogen to glucose, while severe and
prolonged hypoxia in preterm and growth retarded
babies is associated with hypoglycemia. Hypothermia
and hypoglycemia lead to accumulation of non-esterified
free fatty acid and glycerol. Anoxic damage to cells leads
to failure of energy-dependent sodium pump mechanism
with release of potassium and phosphates into the
extracellular fluid.
Assessment of the Infant at Birth
Despite its limitations, Apgar scoring system is conventionally used for assessing the condition of a newborn
baby at one minute afterbirth (Table 3.2.2). The
respiratory effort and heart beats are the most critical
components of Apgar scoring system because muscle
tone, response to reflex stimulus and color are dependent
upon the gestational maturity and cardiorespiratory
status of the baby.
Resuscitation Kit
The resuscitation table or trolley must be available in the
same room where the mother is being delivered. Each

51

TABLE 3.2.2: Apgar scoring system

Score/item

2
Crying

1. Breathing

Nil

Slow

2. Heart rate

Nil

Up to 100

> 100

3. Tone

Flaccid

In-between

Flexed

4. Reflex response

Nil

Grimace

Cry

Blue or pale

Peripheral
cyanosis

Pink

to catheter
5. Color

delivery room must have a well-lighted and warm

microenvironment to receive the newborn baby. The
resuscitation tray must contain a pencil handle laryngoscope with infant (0 and 1) blade, resuscitation bag and
mask, De Lee suction trap, gamma-irradiated disposable
endotracheal tubes with internal diameters of 2.5, 3.0,
3.5, 4.0 mm mounted with adaptors, suction catheters,
syringes and needles, 7.5 percent sodium bicarbonate
solution, epinephrine 1 in 10,000 solution, naloxone,
physiological saline and 5 percent dextrose. Electrical
points and the suction machine should be in working
order. The oxygen cylinder should be checked for its
contents. Sterile neonatal packs containing a bowl,
scissors, cotton swabs and umbilical ties should be
available for each delivery. The bassinet on which the
baby is received should be kept warm and provided with
an overhead radiant heat source and a stop clock to
accurately time the sequence of events afterbirth. It is
mandatory that the resuscitation kit must be checked by
the staff nurse of every duty shift and rechecked by the
physician before each delivery. It is desirable that the
equipment for resuscitation is maintained in a sterile
condition. Above all, the health professional attending
the delivery must be skilled and experienced in the art
of cardiopulmonary resuscitation. The art of endotracheal
intubation should be learnt by continuous practice on
stillborn and dead neonates.
Basic Care of the Baby at Birth
The umbilical cord should be clamped as soon as the
infant is completely delivered. There should be no undue
delay or unnecessary anxiety or hurry to clamp the cord.
Early and immediate clamping of the cord is indicated
in babies with severe birth asphyxia, cord around the
neck and rhesus isoimmunization.

52 IAP Textbook of Pediatrics

Routine Care
Nearly 90 percent of newborns are vigorous term babies
with no risk factors and clear amniotic fluid. These babies
do not need to be separated from their mothers to receive
initial steps. Temperature can be maintained by putting
the baby directly on the mothers chest, drying and
covering with dry linen. Warmth is maintained by direct
skin to skin contact. Clearing of the airway can be done
by wiping the babies nose and mouth.
Assess for the Four Questions (Refer to Algorithm)
If answer is `No to any of these questions, begin initial
steps of resuscitation. Provide initial care (refer to
alogrithm). Provide warmth, position, clear airway (as
necessary), dry, stimulate, reposition and give O2 (as
necessary).
If answer to any of four is `No baby needs initial
steps. In this efforts are directed to prevent hypothermia
and attention is focussed on the airways so that they are
cleared off any secretions and kept patent. The overhead
radiant warmer of the resuscitation trolley or table should
be put on 15 minutes before the birth of the baby. The
baby should be received in a prewarmed linen and dried
from top to bottom immediately afterbirth. The wet linen
should be removed and baby should be covered
effectively with a dry and warm towel. The practice of
bathing the babies soon afterbirth is dangerous and must
be abandoned.
The baby should be placed either in a head low
position to ensure drainage of oropharyngeal secretions
or kept flat with 1/2 inch to 3/4 of an inch towel roll
under the shoulders to maintain slight extension of the
neck for ensuring patency and adequacy of airways. The
mouth should be suctioned first followed up suctioning
of the nose using 10 Fr catheter. The suction force should
be gentle and intermittent using a maximum suction
pressure of 100 mm Hg (136 cm of water). Suctioning
should not be done for more than 5 seconds at a time,

Figure 3.2.1

Figure 3.2.2
Figures 3.2.1 and 3.2.2: Two methods of
tactile stimulation over the soles

and the heart rate should be monitored for possible

bradycardia. These steps usually take around 30 to 45
seconds and by this time most babies are vigorously
crying, actively moving and pink. Centrally cyanosed
baby requires free flow of oxygen with the help of tube
or mask. If the baby is not crying by this time and he or
she is gasping or having no breathing efforts give one or
two flicks or slaps over the soles to stimulate breathing
(Figs 3.2.1 and 3.2.2). Prolonged stimulation or use of
violent maneuvers like pouring cold water on the baby's
face and slapping the back are not only dangerous but
useless resulting in delay in the resuscitation of the baby.
Approach to a Meconium Stained Baby
The amniotic fluid is meconium stained in 10 to 15
percent of deliveries. When baby passes meconium in
utero, there is a chance that the meconium will be
aspirated into infants mouth and potentially into the

Newborn Care
trachea and lungs. Appropriate steps must be taken
immediately after delivery to reduce the risk of serious
consequences resulting from aspiration of the meconium
(Note: Intrapartum suctioning of the mouth and nose after
delivery of the head and before delivering the shoulders is no
longer recommended). Direct endotracheal suctioning,
using the endotracheal tube as a suction catheter, should
be performed in cases of non-vigorous baby born with
meconium stained liquor. Vigorous baby (as defined by
strong respiratory effort, good muscle tone and a HR
>100/mt) do not require endotracheal suction.
Endotracheal suctioning may not be necessary the
newborn is vigorous. The infant may have to be intubated
two to three times till all traces of meconium has been
sucked out and baby has not developed bradycardia. The
meconium-stained baby should never be ventilated till
the air passages have been effectively cleared of all
possible meconium.
Bag and Mask Ventilation
If despite stimulation, the baby is still apneic or having
ineffective ventilation as evidenced by heart rate of less
than 100 per minute, he or she should be given bag and
mask ventilation. The mask should tightly fit on the face
enclosing nose and mouth of the baby. The oxygen
reservoir should be attached to the bag to increase the
concentration of oxygen delivered to the baby (Fig. 3.2.3).
The infant should be ventilated at a rate of 40 to 60 per
minute. There should be a noticeable rise and fall of the
chest during each ventilation (Fig. 3.2.4). Naloxone 0.1
ml/kg should be administered intravenously through
umbilical vein if mother had received pethidine or
morphine within 4 hours before delivery after initiating
baby and mask ventilation. During bag and mask

53

Figure 3.2.4: The procedure of bag and mask ventilation. Mask

should enclose both nose and mouth resting snugly over the
chin and just below the eyes. There should be gentle but visible
rise and fall of chest with each inflation

ventilation, heart rate should be closely monitored after

every 20 to 30 seconds. To save time, heart rate is counted
for 6 seconds and multiplied by 10 to get the heart rate
per minute. If despite effective bag and mask ventilation,
heart rate is not coming up or it further slows down and
drops below 100 per minute, the infant should be
intubated. A large majority of asphyxiated babies can be
effectively revived and resuscitated by using bag and
mask ventilation alone and intubation is usually not
required. There is no role of dexamethasone, atropine,
calcium and respiratory stimulants like nikethamide,
lobeline, etc. in resuscitation. The Apgar scoring system
is not taken into consideration while taking management
decisions during resuscitation of a newborn baby. The
management is guided by the status of breathing, heart
rate and color of the baby. Apgar score may be recorded
at 1 minute, 5 minutes and subsequently (till it is more
than 7) to serve as a prognostic indicator of the outcome
of an asphyxiated baby.
Endotracheal Intubation

Figure 3.2.3: Self-inflatable resuscitation bag and mask. A

reservoir (corrugated tube or a bladder) should be attached at
the air inlet to increase the oxygen concentration delivered to
the baby

Endotracheal intubation is indicated if bag and mask

ventilation fails to maintain adequate ventilation as
evidenced by persistent bradycardia (heart rate below
100 per minute). Infants with diaphragmatic hernia and
thickly meconium stained babies are electively intubated because bag and mask ventilation is contraindicated
in these situations. The art of intubation cannot be taught
and must be learnt by practicing on stillborn babies and
neonates dying in the nursery. The appropriate sized

54 IAP Textbook of Pediatrics

Flow chart 3.2.1: Neonatal resuscitation

(4.0 mm in a term baby and 2.5 mm in a tiny baby)

endotracheal tube should be prepared by shortening it
to 13 cm and attaching a connector. It is easy to intubate
an asphyxiated baby with some practice because of lack
of resistance and hypotonia. The endotracheal tube
should be suctioned before starting positive pressure
ventilation with a bag or machine. The ventilation can
be stopped as soon as the baby establishes spontaneous
breathing and heart rate is maintained above 100 per
minute (See Flow Chart 3.2.1).
External Cardiac Massage and Medications
External cardiac massage is indicated in babies in whom
heart rate drops below 60 per minute despite effective
ventilation. The ventilation should be continued and
simultaneously heart should be massaged either by using

two fingers of one hand or encircling the chest of the

baby with both the hands and applying sternal
compressions with two thumbs (Fig. 3.2.5). Press the
lower part of the sternum to a depth of 1 to 2 cm at a rate
of 90 compressions and 30 ventilations in 1 minute (3:1
ratio) per minute. The thumbs and tips of fingers
(depending upon the method used) should remain in
contact with the sternum all the time, and they should
not be lifted off after each compression. Check the heart
rate after every 20 to 30 seconds, and chest compressions
may be stopped when heart rate goes above 60 per
minute.
If heart rate is not picking up despite effective ventilation and external cardiac massage, administer 0.5 to
1.0 ml of 1.10,000 solution of epinephrine through the
umbilical vein or endotracheal tube. Intracardiac route

Newborn Care

55

administration of 10 ml/kg of fresh blood, fresh frozen

plasma or physiological saline. A skiagram of chest
should be taken to exclude pneumothorax and congenital
malformations of the respiratory system. The infant
should be closely monitored and observed to detect any
manifestations of hypoxic damage to various organs.
Seizures should be promptly managed by correction of
any metabolic disturbances and by administration of
phenobarbitone 20 mg/kg intravenously slowly over 20
minutes. The neurological behavior of the infant should
be closely watched till he or she is able to establish selffeeding.
Figure 3.2.5: Chest compressions with two-finger technique.
Bag and mask ventilation must be continued while providing
chest compressions

is dangerous and should be avoided. The dose of epinephrine may be repeated after 10 minutes. If a baby is
in shock, consider the use of plasma expander (blood,
plasma, saline) in a dose of 10 ml per kg intravenously.
Sodium bicarbonate 1 to 2 ml/kg of 7.5 percent solution
(adequately diluted with equal volume of distilled water
or double volume of 5% dextrose) should be administered intravenously slowly at a rate of 1.0 ml/minute if
effective ventilation is not established even by 10 minutes
or later (Apgar score of less than 7 at 10 minutes).
Early Care of an Asphyxiated Baby
Infants with birth asphyxia should be admitted to the
SCNU for observation and management. A stomach
wash should be done with normal saline and vitamin K
0.5 to 1.0 mg should be given intramuscularly. The infant
should be nursed in a thermoneutral environment.
Intravenous infusion with 10 percent dextrose (without
sodium and potassium) should be started immediately
to prevent any hypoglycemia. Fluid volume should be
restricted to two-thirds because of syndrome of inappropriate antidiuretic hormone (ADH) secretion. Infants
with prolonged birth asphyxia (infants needing bag and
mask ventilation even at 5 minutes) should be given
7.5 percent sodium bicarbonate 1 to 2 ml/kg diluted with
equal volume of distilled water or double volume of
5 percent dextrose slowly to correct any acidosis. Sodium
bicarbonate should be administered only when effective
respirations have been established, otherwise, it will lead
to further accumulation of carbon dioxide in the blood.
Hypovolemic shock should be corrected by the

Prognosis
Early neonatal mortality due to birth asphyxia is higher
in preterm babies, but later neuromotor outcome is often
better in preterm babies as compared to term babies. It is
difficult to prognosticate the future neuromotor outcome
in an individual baby. Most infants with an Apgar score
of 3 or less at 5 minutes do fairly well on follow-up. Term
infants with Apgar of 0 to 3 at 10, 15 and 20 minutes
have mortality rates of 18, 48 and 59 percent respectively;
in survivors the risk of developing cerebral palsy are 5, 9
and 57 percent respectively. Therefore, as a general rule,
a guarded rather than hopeless prognosis should be
communicated to the parents to prevent anxiety.
Relatively adverse outcome is anticipated if 15 minutes
Apgar score is less than 3, cord blood pH of less than 7.0,
hypoglycemia, occurrence of neonatal seizures or
abnormal neurological behavior for more than 7 days
and in infants with acute renal failure. Preterm infants
with evidences of intraventricular or parenchymal
hemorrhage on ultrasound examination of the brain are
likely to manifest neurological handicaps in later life.
BIBLIOGRAPHY
1. Behrman RE, James LS, Klaus M, et al. Treatment of an
asphyxiated newborncurrent opinions and practices
expressed by a panel. J Pediatr 1969;79:981.
2. Cross KW. Resuscitation of asphyxiated infant. Br Med
Bull 1966;22:73.
3. Kattwinkel J. Textbook of Neonatal Resuscitation, 5th ed,
Dallas, American Heart Association, and Elk Grove
Village, Ill, American Academy of Pediatrics 2005.
4. Paul VK, Shankar V, Deorari AK, et al. Tracheal suction
in meconium stained neonates. J Pediatr 1989;144:508.
5. Singh M. Recommendations for creation of a modest level
II neonatal care facilities in India. Indian Pediatr
1992;29:891-94.

56 IAP Textbook of Pediatrics

6.

Singh M. Care of normal newborn babies: Some practical

points. IAP J Pract Pediatr 1993;1:6-13.
7. Singh M. Monitoring of perinatal asphyxia in the
hospital. Indian J Pediatr 1991;58:51.

8. Svenningsen NW, Blennoh G, Lindroth M, et al. Brain

oriented intensive care treatment in severe neonatal
asphyxia. Arch Dis Child 1982;57:176.
9. Sykes GS, Johnson P, Ashworth F, et al. Do Apgar scores
indicate asphyxia? Lancet 1982;27:494.

3.3 Care of a Normal Newborn Baby

Meharban Singh, Ashok K Deorari
Grades of Neonatal Care
Neonatal morbidity and mortality is directly related
to the birth weight and gestational maturity of the
newborn. High-risk pregnancies (which are associated
with the birth of high-risk infants) must be identified
during antenatal period and referred to an appropriate
center for skilled management. Based upon birth weight
and gestational age, a three tier system of neonatal care
is proposed for the developing countries.
Level I Care
Over 80 percent of newborn babies require minimal care
which can be provided by their mothers under the
supervision of basic health professionals. Neonates
weighing above 2000 g or having a gestational maturity
of 37 weeks or more belong to this category. The care
can be provided at home, primary health center level.
Basic care at birth, provision of warmth, maintenance of
asepsis and promotion of breastfeeding form the
mainstay of level I care.
Level II Care
Infants weighing between 1500 and 2000 g or having a
gestational maturity of 32 to 36 weeks need specialized
neonatal care supervised by trained nurses and
pediatricians. First referral units, district hospitals,
teaching institutions and nursing homes should be
equipped to provide intermediate neonatal care.
Equipment for resuscitation, maintenance of thermoneutral environment, intravenous infusion and gavage
feeding, phototherapy and exchange blood transfusion
should be provided. There should be no compromise on
the basic needs of adequate space, nursing staff and
maintenance of asepsis including provision for dispo-

sable gamma-irradiated suction catheters, feeding tubes,

endotracheal tubes, small-vein infusion sets, etc.
Intermediate neonatal care is needed for about 10 to 15
percent of the newborn population and should be
available at all hospitals catering to 1000 to 1500 deliveries
per year.
Level III Care
Intensive neonatal care is required for babies weighing
less than 1500 g or those born before 32 weeks of
gestation. Apex institutions or regional perinatal centers
equipped with centralized oxygen and suction facilities,
servocontrolled incubators, vital sign and transcutaneous
monitors, ventilators and infusion pumps, etc. are best
suited to provide intensive neonatal care. Skilled nurses
and neonatologists especially trained in the art of
neonatal intensive care are required to organize this
service. About 3 to 5 percent of the newborn population
qualify for intensive care. Establishment of intensive care
neonatal center demands a sound infrastructure and
should be envisaged only when optimal intermediate
neonatal care facilities have already been in existence for
some time. The capital and recurring expenditure for
level III care is exhorbitant, and it is not cost-effective
unless the service is regionalized.
Care at Birth
After having ensured that the baby has established
effective breathing, it is essential that all efforts are made
to prevent the occurrence of hypothermia. The baby
should be promptly dried and effectively covered with
prewarmed clothes. The baby should be placed under a
radiant warmer or any heat source during the procedure
of resuscitation. A sterile disposable delivery kit should
be used for each baby to prevent cross-infection. The eyes

Newborn Care
should be cleaned with sterile normal saline using one
swab for each eye. When prophylaxis against gonococcal
ophthalmia is required, it can be ensured either by
instillation of 1.0 percent silver nitrate drops or 0.5
percent tetracycline or erythromycin ophthalmic
ointment. The umbilical cord should be tied using two
ligatures or rubber band or a disposable clamp. The
clamp or ligature should be applied at least 2 to 3 cm
beyond the base of the cord to avoid inadvertent incision
of gut contained in minor exomphalos. The base and tip
of the umbilical stump should be painted with triple dye
or absolute alcohol. Vitamin K 0.5 to 1.0 mg is administered intramuscularly to all babies weighing less than
2000 g, traumatic deliveries following difficult forceps
or vacuum extraction, preoperatively and to babies
whose mothers had received dicoumarol derivatives,
salicylates, anticonvulsants (phenytoin, phenobarbitone)
and antituberculous agents like isoniazid or isonicotinic
hydrazide (INH) and rifampicin. The baby must have
an identification tag before being transferred out of the
labor room.
Quick but thorough clinical screening is essential to
identify any life-threatening congenital anomalies and
birth injuries. The cut end of the umbilical cord should
be inspected for the number of vessels. Normally, there
are two umbilical arteries and one umbilical vein. The
presence of a single umbilical artery is associated with
internal congenital malformations in 15 to 20 percent of
the cases. The commonly associated malformations
include esophageal atresia, imperforate anus and
genitourinary anomalies. Single palmar crease (simian
crease) has increased association with additional
anomalies including Down syndrome. The face and head
should be closely observed for any asymmetry and
dysmorphic features. If while crying the angle of the
mouth and the mandible are pulled down and infant has
asymmetric crying, it is indicative of hypoplasia of the
depressor anguli oris muscle. This is a useful marker of
associated cardiovascular anomalies and congenital
dislocation of hips. The infant should be examined for
location and patency of all the orifices, because anomalies
are frequently encountered around the orifices. The oral
cavity must be examined to exclude the cleft palate. The
patency of the esophagus should be checked by passing
a stiff rubber catheter into the stomach in the following
situations:
i. Small-for-dates baby
ii. Single umbilical artery

57

iii. Polyhydramnios, and

iv. Excessive drooling of saliva.
If there is no esophageal atresia and the catheter has
reached the stomach, gastric contents should be
aspirated. If gastric aspirate exceeds 20 ml in volume, it
is strongly suggestive of high intestinal obstruction due
to pyloric or duodenal atresia. The anomalies are also
concentrated over the midline areas in the front and back,
e.g. spina bifida, meningomyelocele, pilonidal sinus,
ambiguous genitalia, hypospadias, exomphalos, cleft lip,
cleft palate, etc. The abdomen should be palpated for any
masses and heart examined for its position and any
murmurs. Displacement of the heart towards the right
side in association with respiratory difficulty and
resuscitation problems, is suggestive of either diaphragmatic hernia or pneumothorax on the left side.
Breastfeeding
The milk of different mammals is species-specific and
human milk is most suitable to serve the physiological,
biochemical, immunological and emotional needs of the
baby. The low protein content of human milk is in
accordance with the slow rate of growth of the human
infant. The relatively high concentration of lactose and
galactolipids in breast milk is most suited to enhance the
maturation and myelination of the brain which is highly
evolved in human beings.
The preparation and motivation for breastfeeding
should begin during the antenatal period. Inverted and
cracked nipples must be managed during pregnancy so
that the baby is not faced with any mechanical difficulties
during breastfeeding. The mother is advised to put the
baby to the breast as soon as she has recovered from the
exhaustion of labor. According to baby friendly hospital
initiative guidelines breastfeeding should be started
within half an hour of normal delivery and within four
hours of cesarian section. Most babies can be put to the
breast within (half to) one hour of birth. There is no need
for any prelacteal feeds. During the first two to three days,
relatively small quantity of highly concentrated milk
known as colostrum is produced which is extremely rich
in secretory IgA and proteins. It is most suited to serve
the immediate biological needs of the baby. It is essential
that the baby receives the colostrum, and the prevalent
practice of discarding the colostrum must be condemned.
The mother should be advised to feed the baby every
two to three hours on a demand schedule. During each

58 IAP Textbook of Pediatrics

Figure 3.3.1: Burping after a feed helps to eructate swallowed air and reduces the risk of regurgitation after feeds

feed, one breast should be completely emptied before

the baby is put to the other breast. The mother should sit
up comfortably and keep the baby's head slightly raised
and supported on her elbow, and she should offer
alternate breasts at each feed. The baby should not be
allowed to merely suck on the nipple, but he or she must
grasp the areola and part of the breast tissue into his or
her mouth.
After each feed the baby should be burped by holding
him/her upright against the shoulder to prevent
regurgitation of the feeds (Fig. 3.3.1). It is preferable to
put the baby in a prone position or right lateral position
with head end slightly raised to prevent regurgitation
due to gastroesophageal reflux. During the first few days,
many babies fall asleep after taking a few sucks of milk.
It is important that the mother actively interacts with
the baby during breastfeeding. Breastfeeding is not a
passive ritual, and the mother must intently look towards
the baby and gently cuddle and fiddle with the baby by
stroking and tickling behind his or her ears or on the
soles so that he or she does not lapse into sleep without
taking adequate feeds. When the mother perceives that
the baby is becoming slow in his or her sucking efforts,
she should try to gently pull her nipple out when baby
will come out of slumber and restart sucking with
renewed vigor. During the first two to three days, when
lactation is not fully established, the mother is often
anxious that her baby is not getting adequate milk. It
must be explained to her that the act of sucking enhances
lactation and whatever little colostrum the baby receives

during the first few days of life is enough to meet the

nutritional needs of a normal baby. It is absolutely
essential that bottle feeding is not instituted at this stage
with the mistaken belief that lactation is inadequate.
Sucking is the best stimulation both for the enhancement
of milk production and for the ejection of milk. The
mother should be relaxed, free from any anxiety and pain
and reassured that her baby is getting enough nutrition.
Within two to three days, this problem is resolved if
proper support and guidance is given to the mother.
During the first four to six weeks, most babies need to be
fed round-the-clock. Subsequently, one late night feed
and another in the early hours of the morning are enough
to satisfy most babies. During the first four months, the
baby should be exclusively breastfed, and there is no need
to give him or her additional water even during summer
months. This policy is the best safeguard against the
occurrence of infective diarrhea in developing countries.
Ten Steps to Successful Breastfeeding
Every facility providing maternity services and care for
newborn infants should:
1. Have a written breastfeeding policy that is routinely
communicated to all health care staff
2. Train all health care staff in skills necessary to
implement this policy
3. Inform all pregnant women about the benefits and
management of breastfeeding
4. Help mothers initiate breastfeeding within half-hour
of birth
5. Show mothers how to breastfeed, and how to
maintain lactation even if they should be separated
from their infants
6. Give newborn infants no food or drink other than
breast milk, unless medically indicated
7. Practise rooming-in to allow mothers and infants
to remain together throughout 24 hours a day
8. Encourage breastfeeding on demand
9. Give no artificial teats or pacifiers (also called
dummies or soothers) to breastfeeding infants
10. Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge from
the hospital or clinic.
Maintenance of Body Temperature
Newborn babies are homeothermic but their thermoregulatory mechanisms are physiologically unsatisfactory.

Newborn Care
They are very prone to develop hypothermia unless
adequate precautions are taken to protect them. The
environmental temperature that may feel relatively
uncomfortable to an adult may impose serious thermal
stress to a newborn baby. The baby must be kept dried
and effectively clothed using a cap and socks. The ritual
of bathing babies at birth must be condemned. The baby
bath should be delayed till the next day when his or her
temperature has stabilized. During winter, the linen and
clothes of the baby should be prewarmed before dressing.
The room should be kept warm in winter with the help
of a heater. The baby should be nursed in close proximity
to the mother so that the baby is kept warm by maternal
warmth. The oil massage is both culturally and
scientifically acceptable as it provides insulation against
heat loss and reduces insensible water loss. The cultural
practice of keeping the mother-baby dyed isolated for
40 days is useful and needs to be promoted. It prevents
exposure of the baby to cold and safeguards against the
occurrence of infections. In summer months, depending
upon the environmental temperature, the baby should
be dressed in loose cotton clothes and kept indoors as
far as possible. Exposure of the baby to direct sunlight
during the hot summer months can lead to serious
hyperthermia.
Skin Care
The baby should be bathed or sponged on the next day
afterbirth using unmedicated soap and lukewarm water.
Special precautions must be taken during bath to prevent
draught and chilling. It is preferable to perform the ritual
of bathing and nursing toilet of each baby by the cotside. This would provide the unique opportunity and
advantage for imparting health education and active
participation of the mother. The routine use of hexachlorophene for skin prophylaxis is not recommended
because of its risk of toxicity to newborn babies. During
an epidemic of staphylococcal infection, hexachlorophene lotion or medicated soap can be used taking care
that the skin is thoroughly rinsed with water after its
application. Dip baths should be avoided till the cord
has fallen. Special attention should be paid to clean the
scalp, skin creases (neck, axillae, groins) and the diaper
area. Vigorous attempts should not be made to scrub off
the vernix caseosa which provides a protective covering
to the delicate skin of the baby. During the winter months,

59

instead of bathing, the baby can be sponged daily to avoid

unnecessary exposure and risk of hypothermia. During
the procedure of bathing or sponging, the nurse should
specifically look for any superficial infections like
pyoderma, umbilical sepsis, conjunctivitis, oral thrush,
etc. and bring them to the notice of the physician.
Handwashing, barrier nursing and storing separate
articles for personal use of each baby in their individual
lockers is desirable to prevent nosocomial infections.
Care of the Umbilical Stump
The umbilical cord is an important portal of entry for
Clostridium tetani in domiciliary midwifery. Health
personnel must be told the importance of using a sterile
disposable dai-kit to prevent the occurrence of tetanus
neonatorum. The cord should be cut with a sterilized
blade. The umbilical stump must be inspected after 2 to
4 hours of clamping. Bleeding may occur at this time due
to shrinkage of cord and loosening of the ligature. The
use of a rubber band or a disposal clamp safeguards
against the hazard. Triple dye or ethyl alcohol should be
applied at the tip and around the base of the umbilical
stump every day to prevent colonization. The cord must
be left open without any dressing. The cord usually falls
after 5 to 10 days, but may take longer if it has been kept
moistened, when it is infected and in immunocompromised babies. The stump should be inspected for any
discharge or infection and kept clean and dry till
complete healing takes place.
Care of the Eyes
The eyes should be cleaned at birth and once every day
using sterile cotton swabs soaked in sterile water or
normal saline. Each eye should be cleaned using a
separate swab by modified crede method (cleaning from
media) to lateral canthus by swab) saline soaked. The
cultural practice of instillation of human colostrum in
the eyes has been found to be useful in reducing the
incidence of sticky eyes. The practice of applying kajal
in the eyes is not recommended because it may transmit
infections like trachoma or may even cause lead
poisoning. If the eyes are sticky, they can either be
managed by frequent cleaning using sterile cotton swabs
soaked in normal saline or by instillation of 10 percent
sulfacetamide eyedrops every two to four hours. Some

60 IAP Textbook of Pediatrics

neonates may develop persistent epiphora due to
blockage of nasolacrimal duct by epithelial debris. The
mother should be advised to massage the nasolacrimal
duct area (by massaging the outer side of the nose
adjacent to the medial canthus) 5 to 8 times, each time
before she feeds the baby.
Weight Record
Most healthy term babies lose weight during the first 2
to 3 days of life. The weight loss is usually up to 5 to 7
percent of birth weight. The weight remains stationary
during the next one to two days and birth weight is
regained by the end of first week. The factors contributing
to physiological weight loss include removal of vernix
caseosa, mucus and blood from skin, passage of
meconium and reduction of extracellular blood volume.
Delayed feeding and unsatisfactory feeding schedule is
associated with excessive weight loss. There is no need
to monitor early weight changes in a healthy newborn
baby, because it can cause unnecessary anxiety to the
mother and may lead to lactation failure. Babies who are
adequately fed are contented, playful, have good sleep
and are satisfied for at least two to three hours after a
feed. The adequately fed baby passes urine at least 5 to 6
times in a day, while many babies may pass urine (even
stools) after each feed during the first 3 months of life.
The average daily weight gain in term babies is around
30 g, 20 g and 10 g during the first, second, third, fourthmonth periods respectively. Most infants double their
birth weight by 4 to 5 months of age, and triple it by
their first birthday.
Immunization
It is recommended to give the Bacille Calmette-Gurin
(BCG) and a first dose of oral polio vaccine (OPV) as
early as possible preferably within the first week of
life. It should be explained to the mother that the child
must receive all the vaccinations at the proper time
as recommended in the National Immunization
Schedule (Chapter 9, Table 9.1.1). Hepatitis B vaccine
can be administered in 3 doses at birth, 6 weeks and
14 weeks.

Early Identification of Disease

Most mothers do observe their babies carefully and are
often worried by minor physical peculiarities and
problems which are of no serious consequence. She must
be adequately informed and appropriately advised
regarding minor problems to prevent undue anxiety,
concern and worry. The baby-mother dyed should be
approached twice a day to enquire about any feeding
problems, vomiting, bowel disorders and to identify any
problems and relieve the anxiety of the mother regarding
various developmental peculiarities and minor physical
problems which may be bothering her. The onset and
intensity of jaundice should be watched in good natural
daylight. The infant should be closely watched for
following danger signs which should be brought to the
attention of the physician for prompt management:
bleeding from any site, appearance of jaundice within
24 hours of age or yellow staining of palms or soles,
failure to pass meconium within 24 hours or urine within
48 hours, persistent vomiting or diarrhea, poor feeding,
undue lethargy or excessive crying, drooling of saliva or
choking during feeding, respiratory difficulty, apneic
attacks or cyanosis, sudden rise or fall in body temperature, seizures and evidences of superficial infections such
as conjunctivitis, pustules, umbilical sepsis, oral thrush,
etc.
Follow-up
Each baby should be followed up in the well baby clinic
for assessment of growth and development, early diagnosis and management of illnesses and health education
of parents. It is preferable that every baby is seen and
assessed by a health worker at least once every month
for 3 months and subsequently 3 monthly till 1 year of
age.
BIBLIOGRAPHY
1. Davies PA, Robinson RJ, Scopes JW et al: Routine care of
the normal term baby. Medical Care of Newborn Babies
1972;44/45:73.
2. Singh M. Care of the normal baby, Care of the Newborn
(4th edn) Sagar Publications, New Delhi; 1991.
3. Singh M. Care of normal newborn babiessome practical
points. IAP J Pract Pediatr 1993;1:6-13.

Newborn Care

61

3.4 Common Developmental and Physiological

Problems in Newborn Babies
Meharban Singh, Vinod K Paul
Most mothers observe their babies carefully and are often
worried by minor physical or physiological peculiarities
which are of no consequence. It is important that her
complaints are listened to carefully, and they are not
ignored lightly without doing proper evaluation of the
baby. She must be given reassurance and advice
regarding the minor problems and difficulties that may
be bothering her. Adequate explanation and reassurance
is necessary to allay her anxiety which may lead to lactation failure.
Regurgitation of Feeds and Vomiting
Most normal newborn infants regurgitate some amount
of milk soon after feeds. Babies swallow air (aerophagy)
while sucking and as the air is expelled, part of the feed,
looking like curd, also comes out. Unlike vomiting, the
expulsion of stomach contents is without force and
nonprojectile. All mothers must be given proper advice
regarding the technique of feeding and burping after each
feed. The baby must be held upright against the shoulder
or made to sit up in the lap for at least 5 to 10 minutes to
eructate the air swallowed during the feeding before he
or she is put back to the cot. Most babies enjoy being
placed in the prone position which is associated with
less risk of regurgitation, and it relieves abdominal
distention and colic. When vomiting is persistent,
projectile or bile-stained and associated with failure to
pass meconium during the first 24 hours and/or abdominal distention, the baby should be investigated for
intestinal obstruction.
Bowel Disorders
The baby may pass meconium in utero or soon afterbirth,
but all healthy newborn babies must evacuate within 24
hours of birth. During the first two to three days, the
baby passes black, tarry meconium stools which is
followed by greenish (transitional) stools for the next one
or two days. The breastfed baby usually passes 4 to 8
semisolid sticky golden-yellow stools everyday. Some

babies may pass stools after each feed due to the

exaggerated gastrocolic reflex. The stools are often very
small (at times like droppings of the birds) with normal
consistency. The babies continue to gain weight. The
family should be reassured and advised against any
medication as this physiological problem will settle in
due course of time. The breastfed babies may develop
increased frequency of stools if the mother is taking
ampicillin, cephalexin and certain laxatives. Milk of
magnesia, bulk laxatives and a glycerine suppository are
safe for a nursing mother. The administration of glucose
water or honey to the baby may cause osmotic diarrhea
and can lead to infective gastroenteritis due to contamination. When the baby is exclusively breastfed, he or she
is unlikely to develop infective diarrhea. A sudden
change in the baby's established bowel pattern leading
to greater frequency and change in the character of stools
should be taken seriously. Infective diarrhea occurs in
top-fed babies. The stools are often watery with mucus
and plenty of pus cells. Neonatal diarrhea may also occur
in association with septicemia, necrotizing enterocolitis
(NEC), Hirschsprung's disease and phototherapy.
Maternal drug addiction, congenital thyrotoxicosis and
metabolic disorders, such as the salt-losing variety of
congenital adrenal hyperplasia and disaccharidase and
enterokinase deficiency are rare causes of diarrhea in
neonates.
Babies fed on cow's milk are often constipated due to
hard casein curds. Constipation may also occur due to
inadequate feeding or gastrointestinal obstruction.
Infants with congenital hypothyroidism, Hirschsprung's
disease and anal stenosis are often constipated. Mild
constipation in the absence of any underlying disease
process often needs no treatment. Insertion of a glycerine
suppository is often followed by a motion if constipation
is significant. At times offering sugar water, honey or
orange juice for a day or so may be advised. For infants
who are on top-milk, addition of sugar to the feed will
often take care of the problem. The use of laxatives should
be avoided in newborn babies.

62 IAP Textbook of Pediatrics

Delayed Passage of Urine
Most newborn babies pass urine during the first day of
life, but all must void within first 48 hours of birth. If a
baby has not passed urine by 48 hours, he or she should
be examined to rule out renal agenesis and obstructive
uropathy. However, the most common cause of the
alleged nonpassage of the urine is that the baby has
actually passed urine but it has been overlooked by the
mother. The normal frequency of micturition in a
newborn baby varies between (5-10 times per day). Some
babies may cry before passing urine due to discomfort
of a full bladder, they become quiet and dazed while
passing urine and start crying again after having passed
urine due to wet napkins. This should not be considered
as an evidence of urinary tract infection or obstructive
uropathy. The narrow stream of urine, straining and
crying during the act of micturition, dribbling in the end
and presence of palpable urinary bladder or enlarged
kidneys are suggestive of obstructive uropathy.
Physiological Jaundice
About 60 to 70 percent of newborn babies develop
jaundice on the second or third day of life. The icterus is
detectable on the face and the trunk, sparing the palms
and the soles. The serum bilirubin level does not cross
15 mg/dl. Jaundice disappears within 7 to 10 days.
Physiological jaundice does not need any treatment, and
the mother should be reassured that it will disappear
spontaneously. It is not indicative of any infection and
does not require administration of extra water. The
occurrence of jaundice within the first 24 hours of life or
when it is deep and intensely staining the trunk, causing
yellow discoloration of the palms and the soles or if it
persists beyond 2 weeks need investigations and
management.
Jitteriness
Many normal babies are jittery or tremulous on touch
and handling. They are easily startled by loud noise or
rough handling. When jitteriness is excessive and persists
even during feeding, it is important to exclude hypoglycemia and hypocalcemia.
Superficial Infections
Sticky red eyes or purulent conjunctivitis are common
during the newborn period. Gonococcal ophthalmia

should be suspected if there is history of gonorrhea in

the mother or conjunctivitis characterized by abundant
purulent discharge and chemosis of eyelids. It should be
confirmed by microscopic examination of a Gram stained
preparation of purulent discharge. It is best treated by
parenteral and topical administration of crystalline
penicillin and frequent cleaning of eyes. Nongonococcal
purulent conjunctivitis is usually caused by staphylococci, but other pathogens may be responsible
depending upon the microbial ecology of the environment. It is best treated with local instillation of
chloramphenicol or gentamicin eyedrops hourly. After
24 hours intervals between local medications can be
gradually increased. The chlamydial conjunctivitis
characteristically manifests as purulent blenorrhea, often
unilateral, during the second week of life. It is managed
by oral erythromycin therapy (40 mg per kg per day, in
four divided doses) for 2 weeks. In addition, topical
instillation of 10 percent sulfacetamide eyedrops or 0.5
percent erythromycin ophthalmic ointment should be
advised. The eyes should be cleansed with sterile wet
cotton swabs prior to the instillation of eyedrops by using
one swab for each eye.
Pyoderma
Pyoderma manifests as multiple pustules especially over
the scalp, neck, axillae and groins. The infection is usually
transmitted by the hands of personnel and is caused by
staphylococci. The large pustules can be punctured with
a sterile needle to drain the pus. The skin should be
washed with soap and water. The skin lesions should be
painted with triple dye or an antibiotic cream two to three
times a day. When despite this therapy the skin lesions
are increasing in size or number, oral administration of
erythromycin or cloxacillin is recommended. Close
observation for signs of septicemia should be maintained.
Umbilical Sepsis
Umbilical sepsis manifests as redness and edema at the
base of the cord and a foul smelling purulent discharge.
The presence of mucoid discharge on the stump and even
isolation of bacteria are not indicative of umbilical sepsis
unless there are clinical evidences of periumbilical
inflammation or there are pus cells in the exudate. The
umbilical stump should be cleaned with spirit and treated
with local application of triple dye or antibiotic lotion. If
periumbilical inflammation is spreading or the infant is

Newborn Care
showing evidences of systemic spread of infection as
evidenced by fever, lethargy, poor feedings, etc. he or
she should be managed with parenteral antibiotics as in
a case of neonatal septicemia.
Oral Thrush
Oral thrush manifests as white patches with erythematous margins distributed over the tongue and buccal
mucosa. Unlike milk curds, the patches of thrush are
adherent and they often bleed when attempts are made
to remove them. Local application of 0.5 percent aqueous
solution of gentian violent or nystatin or ketoconazole
after each feed is followed by prompt recovery. The
mother should be examined for vaginal and mammary
candidiasis and given appropriate treatment.
Dehydration Fever
During the summer months, when the environmental
temperature approaches 40oC, some healthy newborn
babies may develop transitory fever during the second
or third day of life. The fever is usually moderate in
intensity (up to 38.5oC) and the child is active and keen
to feed. The condition is transient and is best managed
by lowering the environmental temperature. Once the
lactation is established and adequate feeding is ensured,
the infant becomes afebrile.
Excessive Crying
During the first few weeks most newborn babies sleep
during the day and they are awake, playful and
troublesome during the night. This behavior is probably
due to continuation of their in utero pattern of activity.
During pregnancy when the mother is up and about
during daytime, the baby is rocked in the pool of amniotic
fluid and sleeps. During the night when mother is resting,
the fetus is active and playful. Moreover, during the
solitude of night even the normal cry of a baby sounds
too loud and disturbing, both to the mother and the
neighbors. This pattern of activity or behavior spontaneously disappears after 4 to 6 weeks of age. Most babies
usually cry when they are either hungry or are having
discomfort. The cry may be a signal of unpleasant
sensation of a full bladder before passing urine, painful
evacuation of hard stools or discomfort of wet napkins.
At times insect bites, nose block and inapparent trauma
are the reasons for cry. The experienced mother and
physician are able to differentiate between the cry used
as a signal for feed and the cry of discomfort. An infant

63

with abdominal colic would have audible gurgling

sounds in the abdomen and usually feels comfortable
when placed in a prone position which facilitates the
expulsion of gas. The presence of excessive inconsolable
crying or a high-pitched cry is always indicative of
serious disorder like meningitis or a painful inflammatory condition.
Excessive Sleepiness
During the first few days of life, many infants keep their
eyes closed most of the time, and they readily go to sleep
after taking only a few sucks at the breast. This excessive
sleepiness may be aggravated by heavy maternal
sedation during labor. Barbiturates and opium derivatives when taken by the nursing mother may cause
sleepiness in her suckling infant. Infants with Down
syndrome and hypothyroidism are often lazy and lack
activity due to generalized hypotonia. The sudden
appearance of lethargy or lack of interest in feeding, in a
baby who had been feeding adequately in the past, is
often ominous and may be the only manifestation of a
serious illness like septicemia or a metabolic disorder.
Cephalhematoma
It is a subperiosteal collection of blood secondary to injury
during vaginal delivery. It may occur both following an
obstructed or a precipitate delivery. The swelling is not
present at birth and it manifests after a couple of hours
when sufficient amount of blood has extravasated. It is
characterized by a fluctuant swelling which is limited
by suture lines. It gradually resolves over a period of
several days or weeks depending upon the size of the
swelling. Incision or aspiration is contraindicated unless
it gets infected or is associated with critical hyperbilirubinemia.
Cephalhematoma should be differentiated from
caput succedaneum which manifests as a boggy, pitting
edema of the scalp on the presenting part. It is a nonfluctuant swelling and is not limited by the suture lines.
The caput succedaneum is present right at birth and
rapidly disappears during the next 24 to 48 hours.
Umbilical Granuloma
It manifests as a slightly red flesh-like nodule at the base
of the umbilical cord with persistent nonpurulent
discharge after the cord has fallen. This can be managed
by cautery with silver nitrate or application of common
salt for 2 to 3 days.

64 IAP Textbook of Pediatrics

Napkin Rash

Vaginal Bleeding

The perineal skin may become red, indurated and excoriated due to ammoniacal dermatitis if the infant is not
promptly cleaned and dried after the passage of urine or
stools. Occurrence of diarrhea and the use of nylon or
watertight plastic napkins aggravate the condition. The
bottom should be kept dried and exposed to air or
sunlight. Application of coconut oil or a bland ointment
is promptly followed by recovery. The causative factors
should be identified and eliminated. In resistant cases,
infection of the skin by Candida albicans should be ruled
out and appropriately managed with a topical lotion.

About 20 to 25 percent female babies may develop

menstruation like withdrawal vaginal bleeding after 4
to 5 days of birth. The bleeding is usually mild and lasts
for 2 to 4 days. It does not need any specific therapy apart
from local aseptic cleaning of genitals.

Sneezing and Nose Block

Sneezing is common in healthy newborn babies due to
irritation of the nose by amniotic fluid, meconium, blood,
or debris, etc. It should not be considered as a sign of a
common cold. The nostrils should be cleaned with sterile
cotton buds if sneezing is excessive.
Nose block is another common problem. Often there
is no obvious nasal discharge. The infant may be in
discomfort because he or she is an obligatory nose
breather. Severe nose block may even cause respiratory
distress. Nose block is managed by instilling one or two
drops of normal saline into the nostrils 15 minutes before
feeds. Medicated nasal drops are contraindicated in
neonates.

Mucoid Vaginal Secretions

Most female babies have copious grayish white slimy
mucoid vaginal secretions due to female sex hormones.
This should not be confused with purulent vaginal
discharge.
Minor Developmental Peculiarities
Toxic Erythema (Urticaria Neonatorum)
About one-third healthy term newborn babies may
develop an erythematous rash with a central pale papule
on the second or third day of life. The rash usually starts
on the face and spreads to the trunk and extremities in
about 24 hours. The rash disappears spontaneously after
two to three days without any specific treatment. The
exact cause is not known, but it is considered as an early
marker of atopy. The scrappings from the skin lesions
often show increased number of eosinophils. The rash
should be differentiated from pyoderma and skin lesions
of congenital syphilis.

Hiccups

Tongue Tie

Most newborn babies develop hiccups especially after

the feeds. This is normal. The distention of stomach
causes irritation of the diaphragm which leads to hiccups.
They do not indicate any disease process in a newborn
baby, and the mother should be reassured regarding the
benign nature of the hiccups.

A thin frenulum under the tongue is normal and does

not need any treatment. A thick and tight fibrous
frenulum producing a notch at the tip of the tongue is
abnormal and may have to be snipped at the age of three
months. Tongue-tie seldom interferes with sucking or
speech development of the child.

Disorders due to Transplacental

Passage of Hormones

Nonretractable Prepuce

Term babies of both sexes may develop engorgement of

the breasts on the third or fourth day due to effect of
transplacentally transferred progesterone and estrogens.
The hypertrophy of the breast may last for a few days to
several weeks, but it disappears spontaneously. Local
massage, fomentation and temptation to express the milk
may lead to complications.

The prepuce is normally nonretractable in all male

newborn babies, and it should not be diagnosed as
phimosis. The mother should be advised against forcible retraction of the foreskin.
Mongolian Blue Spots
Almost all newborn babies of African and Asian origin
have irregular blue patches of skin pigmentation espe-

Newborn Care

65

cially over the sacral area and buttocks. These patches

have no relationship with Down syndrome, and they
invariably disappear by the age of 6 to 18 months.

date babies. Dryness of skin occurs due to the paucity of

amniotic fluid. Application of an emollient cream or oil
provides relief.

Congenital Teeth

Subconjunctival Hemorrhage

Some newborn babies may be born with one or two lower

incisor teeth. They do not interfere with feeding, but
cause considerable anxiety among the parents and
relatives due to the mistaken cultural belief that they are
a bad omen. The loose teeth may be extracted as a
safeguard against the risk of aspiration.

In some babies semilunar spots of subconjunctival

hemorrhage may be seen over the outer canthus of the
eye. They are seen in babies born by vaginal delivery
following vertex presentation. The hemorrhage gets
resorbed after a few days.

Milia

The spear-shaped xiphisternal cartilage may stand out

prominently in some babies, and it is not indicative of
any disease process.

Yellow white pinhead-sized papules on the nose are seen

in practically all babies. They occur due to the retention
of sebum and disappear spontaneously.

Prominent Xiphisternum

BIBLIOGRAPHY
1.

Excessive Scales and Peeling of Skin

Dry scaly skin with peeling and increased transverse skin
creases is seen in post-term and some term small-for-

Singh M. Common neonatal problems and their

management. Indian Practitioner 1970;23:65.
2. Singh M, Krishnamoorthy KS, Sinclair S, et al. Some
developmental characteristics in the newborn. Indian
Pediatr 1970;7:378.

3.5 Management of Low Birth Weight Babies

Vinod K Paul, Ashok K Deorari, Meharban Singh
INTRODUCTION
The average birth weight of a newborn baby in our
country is around 2800 to 3000 g. A neonate who weighs
less than 2500 g at birth is a low birth weight baby (LBW).
In India, over 30 percent infants are born LBW.
Nearly 80 percent of neonatal deaths and 50 percent
of infant deaths occur among the LBW neonates. Even
after recovering from neonatal complications, some LBW
babies are prone to develop malnutrition, recurrent
infections, and neurodevelopmental handicaps. There is
emerging evidence that LBW or growth-retarded
neonates are more prone to manifest diabetes mellitus,
hypertension and coronary artery disease in later life.
Therefore, LBW is a key risk factor for adverse outcome
in life.
The newborn baby may be LBW because of prematurity or intrauterine growth retardation (IUGR). A baby
born before 37 weeks of gestation is called a preterm baby.

Fetal size and weight are directly linked to gestation.

Therefore, it is obvious that if the delivery takes place
prematurely, the baby is likely to be small. Approximately one-third of LBW neonates in our country are
preterm. The second situation that leads to LBW is IUGR.
The gestation may be full term or preterm, but the baby
is undernourished, undersized and, therefore, LBW. Such
a baby is also called a small-for-date (SFD) baby. Twothirds of our LBW neonates fall in this category. At times,
an LBW neonate may be both preterm as well as SFD.
Etiology
Poor nutritional status of the mother and frequent
pregnancies are the major causes of IUGR. Mothers with
a weight of less than 40 kg and a height of less than
145 cm often give birth to SFD babies. Insufficient
nutritional intake during pregnancy also has an adverse
effect on fetal growth. Maternal hypertension,

66 IAP Textbook of Pediatrics

preeclampsia, postmaturity, frequent pregnancies,
multiple pregnancy, anemia, malaria and tobacco use are
other causes of IUGR. Chronic maternal diseases of heart,
kidneys, lungs or liver may also lead to IUGR.
Preterm labor occurs in teenage mothers and in the
setting of low maternal weight, cervical incompetence,
antepartum hemorrhage, previous fetal loss, previous
preterm delivery. Sometimes, preterm labor is medically
induced for the sake of the baby as in the case of Rhisoimmunization or maternal diabetes mellitus. The
cause of a majority of preterm deliveries, however,
remains unknown.
How to recognize Two Types of LBW Neonates?
It is desirable and of practical relevance to make clinical
distinction between the two types of LBW babies. A
preterm baby is diagnosed on the basis of the period of
gestation calculated from the last menstrual cycle of the
mother. If it is less than 37 completed weeks, the baby is
designated as preterm. Preterm babies also have distinct
physical and neurological features which help in their
recognition. The deep skin creases over the soles are
present only over the anterior one-third. The external ear
or the pinna is soft and devoid of cartilage, and it does
not recoil back promptly on being folded. In males, the
scrotum does not have rugae and testes may not be
descended into the scrotum. In female infants, the labia
are widely separated and do not cover the labia minora,
resulting in the prominent appearance of the clitoris. The
back of the preterm babies has abundant growth of fine
hair called lanugo.
Small-for-dates neonates have an emaciated look and
loose folds of skin because of lack of subcutaneous tissue.
These are particularly prominent over the buttocks and
the thighs. They look alert and often plethoric. In SFD
babies, the head circumference exceeds the chest
circumference by more than 3 cm. The SFD babies are
often full term or borderline term in gestation. When their
birth weight is plotted on the intrauterine growth chart,
it falls below the tenth centile.
Problems of LBW Neonates
Preterm Babies
The basic underlying feature of the preterm LBW infant
is immaturity of their organ systems. They may not
establish respiration satisfactorily at birth and develop
asphyxia necessitating expert resuscitation. All newborn

babies keep themselves warm by active metabolism in

the brown fat. The preterm babies lack adequate stores
of brown fat and are, therefore, vulnerable to become
hypothermic at the usual ambient temperatures unless
specific measures are taken to keep them warm. Preterm
neonates less than 34 weeks of gestation do not have
coordinated sucking and swallowing movements.
Therefore, they are unable to suck at the breast and are
liable to get choked. Preterm infants, especially those less
than 30 weeks of gestation may not tolerate enteral feeds
initially because of immaturity of gut. Infants born before
34 weeks of gestation have immature lungs which do
not expand well afterbirth and are, therefore, unable to
perform the function of gas exchange. They develop
respiratory distress syndrome (RDS) characterized by
rapid and labored respirations, indrawing of the chest,
grunting and cyanosis. Because of the immature respiratory control mechanisms, these babies also have a
tendency to manifest apneic spells. These infants have
immature vascular beds around the cerebral ventricles.
The delicate vessels may rupture and cause intraventricular hemorrhage (IVH). Immature metabolic pathways
of preterm infants predispose them to the development
hypoglycemia, metabolic acidosis, and hyperbilirubinemia. Infection is another major problem among
preterm babies and indeed an important cause of
mortality. These babies do not have efficient humoral,
cellular and mucosal immune mechanisms to protect
themselves against infections. Besides, interventions such
as needle pricks and intravenous lines, especially in the
setting of a contaminated environment, predispose them
to develop potentially fatal bacterial infections. Preterm
infants may develop blindness due to retinopathy of prematurity (ROP) as a result of hyperoxia due to unmonitored oxygen therapy.
Small-for-date (SFD) Babies
The neonatal complications in SFD babies occur due to
in utero undernutrition and hypoxia. The stress of labor
may lead to fetal distress, meconium passage in utero and
birth asphyxia. Respiratory distress may occur due to
meconium aspiration syndrome. Due to chronic fetal
malnutrition, they also lack adequate brown fat stores.
This predisposes them to develop hypothermia. They are
also prone to develop hypoglycemia because of
insufficient glycogen stores. Like preterm babies, they
are also vulnerable to develop neonatal sepsis. SFD
infants are more likely to have congenital malformations
as compared to their normal counterparts.

Newborn Care
Management
Delivery of LBW Babies
Ideally, the delivery of an anticipated LBW baby should
be conducted in a hospital. Premature labor as well as
IUGR are indications for referral of the pregnant mother
to a center with well-equipped facilities. The in utero
transfer of a low weight fetus is far more desirable, convenient and safe than the transport of a LBW baby
afterbirth. Delivery should be conducted by trained
health professionals, at least one of them should be wellversed with the art of neonatal resuscitation. Resuscitation equipment like suction catheters, bag and mask,
oxygen cylinder, laryngoscope, etc. should be kept ready
beforehand. Baby must be provided warmth from a heat
source like a heater, or a lamp with 200 W bulb to prevent
hypothermia.
The Place of Care
An LBW newborn with a birth weight of 1800 g or above,
or a gestation of 34 weeks or more can be managed at
home by the mother and the family under the supervision
of a health worker or a family physician. The following
infants should be hospitalized for care:
i. birth weight of less than 1800 g
ii. gestation of less than 34 weeks
iii. neonate who is not able to take feeds from the breast
or by katori-spoon (irrespective of birth weight and
gestation)
iv. a sick neonate (irrespective of the birth weight or
gestation).
Keeping the LBW Babies Warm
Provision of warmth to prevent hypothermia is one of
the cardinal principles of newborn care. A baby under
cold stress wastes energy and oxygen in trying to maintain temperature. Hypothermia can lead to hypoglycemia, bleeding diathesis, pulmonary hemorrhage,
acidosis, apnea, respiratory failure, shock and even death.
All this is entirely preventable through the following
simple measures.
First and foremost, the mother herself is a source of
warmth for the baby. It is of immense help to nurse the
baby next to the mother, in between the breasts over the
chest, in Kangaroo positioin, day and night. Further, the
room where an LBW baby is nursed should be kept warm
(temperature between 28oC to 30oC in all weathers). This

67

temperature is slightly uncomfortable for adults, but this

discomfort should be accepted for the sake of the baby.
While in summer months no extra effort is required to
maintain this temperature, in winter a room heater or
any other warming device may have to be used. The baby
should be clothed well. Two or three layers of clothes
are generally required. If the room is not warm enough,
woollen sweater should also be put on. Feet should be
covered with socks, hands with mittens and head with a
cap. Besides, a blanket should be used to cover the baby.
The temperature regulation of the baby is satisfactory
when the trunk feels warm to touch, while the soles and
the palms are pink and warm. In early stages of
hypothermia, the trunk is warm, but the soles and palms
are cold to touch. This is not normal and baby requires
additional warmth immediately to prevent cold stress
and its adverse consequences.
In the hospital apart from the above methods,
overhead radiant warmer or incubator may be used to
keep the baby warm. Regular monitoring of axillary or
skin temperature with a low-reading thermometer (30oC40oC) should be carried out in all the hospitalized babies.
Nutrition and Fluids
Birth weight, gestation, presence or absence of sickness
and individual feeding effort of the baby determine the
decision as to how a LBW neonate be provided with
fluids and nutrition (Table 3.5.1). Ultimate goal is to meet
both these needs from direct and exclusive breastfeeding.
Neonates weighing less than 1200 g or a gestation of
less than 30 weeks, or those having sickness should
receive IV fluids initially. Enteral feeds should be introduced gradually by gavage as the babys acute problems
begin to settle. In due course, the baby is shifted to katorispoon feeds, and then the direct breastfeeds.
Infants weighing 1200 to 1800 g (or 3034 weeks
gestation) and not having any significant illness should
be put on gavage feeds initially. In a couple of days, it
should be possible to shift them to katori-spoon feeds, and
then gradually to breastfeeds.
In order to promote lactation and enable the baby to
learn sucking, all babies on gavage or katori-spoon feeds
should be put on the breast before each feed for 5 to 10
minutes. With improvement in their overall condition,
the infants would start meeting a part and, later on all of
their nutritional needs from direct breastfeeding. Breast
milk is the best milk for a LBW baby.

68 IAP Textbook of Pediatrics

TABLE 3.5.1: Guidelines for the modes to provide fluids and
nutrients to LBW babies
Age
Birth weight
Gestation
Initial

After 13 days

Categories of neonates
<1200 gm
<30 weeks

1200-1800
30-34 weeks

Intravenous
fluids. Try
gavage feeds
if not sick

Gavage

Gavage

Katori-spoon

>1800
> 34 weeks
Breastfeeding.
If unsatisfactory give
katori-spoon
feeds
Breast

Later (24 weeks) Katori-spoon

Breast

Breast

After some more

time (46 weeks)

Breast

Breast

Breast

Note:
1. For gavage and katori-spoon feeds, use expressed breast
milk only. Start with small volume, and gradually buildup.
2. When the baby is on gavage or katori-spoon feeds, it is
important that he is put on the breast before every feed.
Although the baby may not obtain much milk, it will help
promote lactation and enable the baby to learn how to
suck.
3. When shifting a baby from one mode of feeding to
another, be very careful. Introduce the new mode for only
some of the feeds to begin with and then build-up
gradually.
4. The feeding of every baby should be individualized. The
above recommendations should only serve as broad
guidelines.

Most LBW babies weighing more than 1800 g or over

34 weeks of gestation are able to feed directly from the
breast. However, some of them may not be able to do so
satisfactorily during the first few days of life. During this
period, the feeds may be provided with a katori-spoon.
Breast milk is the ideal food for a LBW baby. It is
well to remember that the breast milk of the mother of
the LBW baby contains appropriately higher content of
protein and calories and is uniquely suited to provide
near optimum nutrition to her LBW baby. The milk is
thus not only species specific, it is baby specific. If lactation is inadequate in spite of best efforts, the baby should
be carefully evaluated for supplementary feeding with
top milk. Feeding with a substitute milk other than breast
milk should be reserved essentially for the hospitalized
babies and resorted to for the minimum necessary period

until breast milk feeding can be ensured. Any formula

providing (per dl) about 2 g protein (whey-dominant),
4.0 g fat (containing polyunsaturated fatty acids and
medium chain triglycerides), and 10 to 12 g of carbohydrate (as lactose and maltodextrins) and 70 to 80
kilocalories is quite suitable. If it is not possible to afford
a formula milk, any milk obtained for household use may
be fed to the baby without dilution.
It is emphasized that the decision to feed a substitute
milk other than breast milk is a very major decision and
must not be taken lightly. Only when all avenues for
obtaining breast milk are exhausted, should one resort
to this choice as an interim and unavoidable choice.
Amount and Frequency of Enteral Feeds
For infants on gavage or katori-spoon feeds, total daily
requirements can be estimated from the table on the fluid
requirements (Table 3.5.2). In a stable, growing LBW baby
daily intake of feeds should be gradually built up to 180
to 200 ml/kg. LBW babies should be fed every 2 hours
starting at 2 hours of age. Two hourly feeds are also
applicable to LBW receiving direct breastfeeding. LBW
babies may take longer on the breast as compared to their
normal weight counterparts.
TABLE 3.5.2: Fluid requirements of neonates
(ml per kg body weight)
Day of life

Birth weight
>1500 g

1000 to 1500 g

<1000 g

60

80

100

75

95

115

90

110

130

105

125

145

120

140

160

135

155

175

7 onwards

150

170

190

Note:
1. On the first day the fluid requirements range from 60 to
100 ml/kg, (the difference between the three categories
being 20 ml/kg each).
2. The daily increment in all groups is around 15 ml per kg till
day 7.
3. Extra 20 to 30 ml/kg fluid should be added for infants
nursed under a radiant warmer. For those receiving
phototherapy add extra 10 to 15 ml/kg fluid.
4. These are general guidelines, fluid therapy of every baby
should be individualized.

Newborn Care
Technique of Feeding
Gavage feeds For gavage feeding, Fr 5 polythene feeding
catheter is used for nasogastric or orogastric placement.
For nasogastric insertion, the catheter is measured from
the external nares to the tragus of the ear, and from there
to the ansiform cartilage, and marked. This length of the
tube should be inserted through the nose. For the
orogastric catheter the distance between angle of the
mouth to tragus and then to the ansiform cartilage is used
for insertion. During nasogastric or orogastric insertion,
the head is slightly raised and a wet (not lubricated)
catheter is gently passed through the nose (nasogastric)
or mouth (orogastric) down through the esophagus to
the stomach. Its position is verified by aspirating the
gastric contents, and by injecting air and auscultating
over the epigastric region. At the time of feeding, the
outer end of the tube is attached to a 10 or 20 ml syringe
(without plunger) and milk is allowed to trickle by
gravity. At the end, about 2 ml of sterile water should be
injected to rinse the tube. The baby should be placed in
the right lateral position for 15 to 20 minutes to avoid
regurgitation. There is no need to burp a gavage-fed baby.
The polythene nasogastric or orogastric tube may be
inserted before every feed or left in situ for 2 to 3 days.
While pulling out a feeding tube, it must be kept pinched
and pulled out gently while applying constant negative
pressure with a syringe to avoid trickling of gastric
contents into the trachea.
Gavage feeding may be risky in very small babies.
They have a small capacity of stomach and the gut may
not be ready to tolerate feeds. Stasis may also result from
paralytic ileus due to autonomic immaturity. Thus,
gavage-fed preterm babies are candidates for regurgitation, aspiration and necrotizing enterocolitis (NEC).
Before every feed, the abdominal girth (just above the
umbilical stump) should be measured. If the abdominal
girth increases by more than 2 cm from the baseline, the
baby should be evaluated carefully for any illness. The
enteral feeds may have to be suspended till the
abdominal distention improves.
Katori-spoon feeds Feeding with a spoon (or a similar
device such as paladai') and katori (or any other receptacle such as a cup) has been found to be safe in LBW
babies. This mode of feeding is a bridge between gavage
feeding and direct breastfeeding. It is based on the
premise that neonates with a gestation of 30 to 32 weeks
or more are in a position to swallow the feeds satis-

69

factorily even though they may not have coordinated

sucking efforts. The required amount of expressed breast
milk is taken in a katori. The baby is placed in a semiupright posture with a napkin around the neck to mop
up the spillage. The spoon is filled with milk, a little short
of the brim, placed at the lips of the baby in the corner of
mouth. The baby will actively swallow the milk. The
process is repeated till the required amount has been fed.
With paladai the tapering snout is placed at the angle of
the mouth and milk is allowed to be trickled gradually
as the baby swallows it.
If the baby does not actively accept and swallow the
feed, try to arouse the baby with a gentle stimulation. If
he or she is still sluggish, do not insist on this method. It
is better to switch back to gavage feeds till the baby is
better prepared.
Breastfeeding The method of breastfeeding is essentially
the same as for the normal weight babies. LBW babies
may be slow in sucking and take longer time to feed.
Assessment of Adequacy of Nutrition
The key measure of optimal feeding is the weight pattern
of the baby. A LBW baby loses up to 1 to 2 percent weight
everyday amounting to 10 to 15 percent cumulative
weight loss during the first week of life. Birth weight is
regained between 10th and 14th day. All babies start
gaining weight by the second week of life at a rate of
about 15 to 20 g per day (12% of birth weight). It is
important to note that the SFD-LBW babies who are
otherwise healthy should not have any appreciable
weight loss at all, and they should start gaining weight
early. It is desirable to weigh all LBW babies at the
postnatal age of 2 weeks (to check regaining of the birth
weight), 4 weeks (to ascertain a weight gain of at least
200300 g) and then every month. Hospitalized LBW
babies should be weighed everyday on an accurate
weighing scale.
Excessive weight loss, delay in regaining birth weight
and poor weight gain are suggestive of inadequate
feeding, cold stress, excessive insensible water loss or
systemic illness (like anemia, sepsis, late metabolic
acidosis, etc.).
Nutritional Supplements
All LBW babies should receive intramuscular vitamin K
1.0 mg at birth. Vitamin A and D are required in doses of
1000 IU and 400 IU everyday, respectively, from 2 weeks

70 IAP Textbook of Pediatrics

of age. At 8 weeks of age, iron supplements should be
started in a dose of 2 mg/kg/day. Very low birth babies
(<1500 g, <32-wk gestation) need vitamin E, calcium and
phosphorus supplementation till 37 weeks.

written note covering the antenatal, intranatal and

neonatal details along with the baby.
Prognosis

The cornerstone of care of the newborn infants, more so

for the LBW babies, is anticipation and early detection
of complications. This is achieved by careful monitoring
of the babies. Clinical monitoring is the most important
and practical method. It involves periodic evaluation for
signs of illness. These include lethargy, refusal to feed,
hypothermia, respiratory distress, grunt, apnea,
abnormal weight gain pattern, jaundice over soles and
palms, abdominal distention, feed intolerance, cyanosis,
pallor, sclerema, seizures and bleeding. A baby who
shows anyone or more of the above signs/symptoms
should be immediately referred for hospitalization for
prompt management of the specific complications by a
neonatologist.

Mortality of LBW babies is inversely related to the

gestation and birth weight, and directly to the severity
of illness and complications. Because of functional
immaturity of various body organs, the preterm babies
do rather poorly than the corresponding weight SFD
babies in the immediate neonatal period. Adequacy of
management at birth also makes a major difference. The
LBW who experiences significant birth asphyxia or
develops hypothermia soon afterbirth is seriously
compromised, no matter what heroic measures are instituted later on.
Long-term outcome of LBW infant depends upon gestation, birth weight and nature and severity of complications. In general, over 90 percent of LBW babies who
survive the newborn period have no neurodevelopmental handicaps. Optimal and effective care of the LBW
neonates is thus a highly rewarding experience.

Vaccination of LBW Babies

BIBLIOGRAPHY

Early Detection of Sickness and

Management of Complications

If the LBW baby is not sick, the vaccination schedule is

the same as for the normal babies. BCG, OPV and HBV
should be given at the time of discharge.

1.

Transport of a Sick LBW Baby

3.

It is essential to provide warmth during transport to

prevent cold injury. The baby should be clothed and
placed in a prewarmed basket or box, but a transport
incubator is ideal. Hot water rubber bottles may be used
as heat source. However, make sure to cap them tightly
and wrap 2 layers of towel to avoid direct contact with
the baby. Mother of the baby should also be transferred
to the hospital along with the baby as far as possible.
This will allay her anxiety and ensure breast milk feeding
of the baby. Placing the baby next to mother's body
during transport will provide the necessary warmth to
the child during the journey.
The infant should be stabilized before transport as
far as possible. A doctor or nurse should accompany the
baby, if possible. The referring doctor should send a

2.

4.
5.
6.
7.
8.
9.

American Academy of Pediatrics. Committee on

Nutrition. Nutritional needs of low birth weight infants.
Pediatrics 1985;75:76.
American Academy of Pediatrics. Pediatric Nutrition
Handbook 1993.
Arora NK, Paul VK, Singh M. Morbidity and mortality
in term infants with intrauterine growth retardation. J
Trop Pediatr 1987;33:186.
Jeeva Sankar M, Agarwal R, Mishra S, Deorari AK, Paul
VK. Feeding of low birth weight infants. Indian J Ped
2008;75:459-69.
Singh M. Disorders of weight and gestation. Care of
the Newborn. Sagar Publications: New Delhi 1991;11225.
Singh S, Singh M: Birth weight to birth weight
postnatal weight pattern of preterm infants. Indian J
Pediatr 1979;46:223.
Tsang RC, Lucas A, Uauy R, et al. Nutrition Needs of
the Preterm Infant Williams and Williams: London 1993.
Tsang RC, Nichols BL. Nutrition During Infancy Hanley
and Belfus: St Louis 1997.
World Health Organization. Kangaroo mother care: a
practical guide, Department of reproductive Health and
Research, WHO, Geneva 2003.

Newborn Care

71

3.6 Common Diseases of Newborn Babies

Meharban Singh, Vinod K Paul, Ashok K Deorari
A large majority of newborn babies do not develop any
serious difficulties and they need level I or minimal
newborn care which can be provided by the mother
under the supervision of a nurse. High-risk mothers are
likely to give birth to preterm or low birth weight (LBW)
babies which are prone to suffer from a number of
disorders. Common causes of morbidity in newborn
babies include respiratory distress syndrome (RDS),
septicemia and hyperbilirubinemia. These disorders
affect 10 to 12 percent of neonates in our institution. Most
neonatal disorders and deaths are limited to preterm and
LBW babies.
Respiratory Distress Syndrome
Respiratory difficulties are encountered in 5 to 7 percent
of newborn babies, while pulmonary pathology is the
most frequent autopsy finding in the neonates. The
clinical diagnosis of respiratory distress is suspected
when the respiratory rate is more than 60 per minute in
a quiet resting baby, and there are either inspiratory costal
recessions or expiratory grunt.
Causes
The common causes of RDS in newborn babies include
pneumonia, meconium aspiration syndrome, transient
tachypnea of the newborn, hyaline membrane disease
(HMD) and congenital malformations of respiratory and
cardiovascular systems. The infant should be assessed
for degree of distress, severity of intercostal recessions,
cyanosis, activity or alertness, nature of cry, feeding
behavior and status of peripheral circulation.
Meconium Aspiration Syndrome (MAS)
Meconium is passed in utero by 10 to 15 percent of infants,
and it suggests that the fetus may have suffered from an
asphyxial episode. The baby may be asphyxiated at birth
and may be covered with meconium. The yellow staining
of the cord, skin and nails suggests that the baby had
been soaked in meconium for several hours. The presence
of thick particulate matter (pea-souped appearance of
amniotic fluid) is associated with increased risk of MAS.

When management of the meconium-stained baby

is unsatisfactory at birth, there is a potential risk of
development of MAS. The baby is often asphyxiated at
birth and develops progressive respiratory distress soon
afterbirth. There is marked inspiratory intercostal
recessions and expiratory grunt. The chest may be overinflated or barrel-shaped due to obstructive emphysema.
The chest radiogaph shows bilateral coarse, irregular
densities with patches of obstructive emphysema. The
management is mostly supportive by maintaining
thermoneutral environment, adequate hydration and
oxygenation. There is no therapeutic utility of either
routine antibiotics or corticosteroids. All efforts should
be made to prevent morbidity due to MAS by avoiding
delay in the delivery of such babies and by ensuring
prompt and effective endotracheal suction of nonvigrous
baby at birth.
Transient Tachypnea of the Newborn (TTNB)
Transient tachypnea of the newborn (TTNB) is characterized by the development of rapid shallow breathing
in a baby at birth or few hours later. The condition is
more common in term babies born by cesarean section.
The respiratory rate may vary from 60 to 100 per minute
while intercostal recessions are either absent or minimal.
The baby remains alert and active and maintains good
color. The condition occurs due to failure of drainage of
amniotic fluid through the lymphatics leading to reduced
lung compliance. A skiagram of the chest shows linear
streakings at both hila due to dilated lymphatics and
presence of fluid in the interlobar fissure. The condition
resolves spontaneously without any specific therapy
within two to three days of life. Some infants may require
administration of 40 percent oxygen to maintain good
color.
Hyaline Membrane Disease
(Idiopathic Respiratory Distress Syndrome)
Hyaline membrane disease (HMD) is the most common
cause of respiratory morbidity in preterm babies. It affects
10 to 15 percent of preterm babies in India though its

72 IAP Textbook of Pediatrics

incidence is relatively higher in the West. The condition
occurs due to a lack of pulmonary surfactant because of
the immaturity of the lungs. When surface-active
material is deficient in the alveoli, there is alveolar
collapse during expiration. Apart from prematurity, the
production of surfactant may be compromised by
damage to type II alveolar cells due to birth asphyxia,
acidosis, hypothermia, antepartum hemorrhage and
shock. Infants delivered by emergency cesarean section
are predisposed to develop HMD due to greater chances
of perinatal hypoxia.
The pulmonary immaturity of the fetal lungs can be
assessed by determination of lecithin/sphingomyelin
ratio in the amniotic fluid. Lecithin/sphingomyelin
(L/S) ratio of 2 or more is suggestive of adequate lung
maturity, while a ratio of less than 1.5 is often associated
with HMD. Amniotic fluid shake test is a simple
bedside test for assessment of lung maturity. Estimation
of phosphotidyl glycerol is a more specific indicator of
lung maturity (especially in diabetic mothers), and its
absence is invariably associated with development of
HMD.
Clinical Features
Hyaline membrane disease is characterized by a triad of
tachypnea, expiratory grunt and inspiratory retractions
in a prematurely born asphyxiated infant. The symptoms
may begin at birth or within 6 hours of delivery. There is
gradual worsening of retractions, grunting and cyanosis.
During the next 24 to 48 hours, the course of disease is
relentlessly progressive and may be complicated by
patent ductus arteriosus (PDA). A gastric aspirate shake
test is usually negative. The skiagram of the chest shows
the air bronchogram extending beyond the left cardiac
border followed by diffuse opaque appearance due to
solid lungs.
Management
Premature labor should be arrested by appropriate
tocolytic therapy to gain pulmonary maturity. The
induction of labor should be delayed as far as possible
till pulmonary maturity is confirmed by the results of
amniotic fluid L/S ratio or level of phosphatidyl glycerol.
When premature labor below 34 weeks of gestation is
unavoidable, the mother should be administered
betamethasone 12 mg IM every 24 hours for two doses
or dexamethasone 6 mg intramuscularly four doses at
an interval of every 12 hours.

The infant should be nursed in a thermoneutral

environment and administered oxygen through a head
box. An intravenous line should be established to
maintain fluid and electrolyte balance, for the correction
of acidosis and administration of drugs. Intratracheal
administration of synthetic surfactant is associated with
improved survival and reduced risk of complications.
Arterial oxygen saturation should be monitored with the
help of a pulse oximeter. When arterial oxygen saturation
cannot be maintained above 90 percent despite providing oxygen in the head box at a concentration of
40 percent, the infant should be provided continuous
positive airway pressure (CPAP) through silastic nasal
prongs. When CPAP is also ineffective to maintain
adequate oxygenation, the baby is managed by intermittent positive-pressure ventilation (IPPV). The acidbase parameters and blood gases should be monitored
frequently to correct acidosis and hypoxia or hyperoxia.
Unmonitored high concentrations of oxygen in preterm
babies may lead to retinopathy of prematurity (ROP) due
to oxygen toxicity. Antibiotics are administered
whenever there is suspicion of superadded bacterial
infection. The management of HMD demands excellent
supportive care by trained nurses and the availability of
high technology to monitor and manage the hypoxia due
to ineffective ventilation. The case fatality rate due to
HMD is related to the quality of neonatal care and varies
between 25 and 50 percent.
Congenital Malformations
Respiratory distress in the newborn may occur due to a
number of congenital malformations of pulmonary
system or due to congestive heart failure because of
congenital heart disease. The common respiratory
malformations include choanal atresia, Pierre Robin
syndrome, esophageal atresia with tracheoesophageal
fistula, diaphragmatic hernia and vascular rings.
Congenital and postnatal pneumonia is an important
cause of RDS and is discussed under neonatal sepsis.
Neonatal Sepsis
(Septicemia, Pneumonia and Meningitis)
Systemic bacterial infections of newborn infants are
termed neonatal sepsis. This is a generic term which
incorporates neonatal septicemia, pneumonia, meningitis
and urinary tract infections which may manifest clinically
in isolation or in different combinations. They are the
most common cause of neonatal deaths in India. Low

Newborn Care
birth weight is an important underlying condition. In
neonatal septicemia, the infant has overwhelming
bacteremia with poor localization of infection into any
particular organ system. The clinical manifestations are
characteristic albeit nonspecific. Pneumonia manifests as
respiratory distress. Meningitis is often silent clinically
with a clinical picture dominated by manifestations of
associated septicemia. Appearance of excessive highpitched crying, fever, seizures, blank look and bulging
anterior fontanelle are suggestive of meningitis.
Neonatal sepsis can be divided into two subtypes
depending upon whether the onset of symptoms is
during the first 72 hours of life or later. Early-onset infections are caused by organisms prevalent in the genital
tract or in the labor room and maternity operation theater.
It often manifests as pneumonia causing respiratory
distress. The predisposing factors for early-onset sepsis/
pneumonia include prolonged premature rupture of
membranes (PPROM), foul smelling liquor, multiple per
vaginal examinations, maternal fever, difficult or
prolonged labor and aspiration of meconium.
Late-onset septicemia is caused by the organisms
thriving in the external environments of homes or
hospitals. The infection is often transmitted through the
hands of the care providers. The onset of symptoms is
usually delayed beyond 72 hours afterbirth and the
presentation is that of septicemia, pneumonia or
meningitis. The predisposing causes of late-onset sepsis
include: lack of breast milk feeds, superficial infections
(pyoderma, umbilical sepsis), aspiration of feeds,
disruption of skin integrity with needle pricks and use
of intravenous fluids. These factors enhance the chances
of entry of organisms into the body systems of neonates
who are much less immunocompetent as compared to
older children and adults. The common organisms
responsible for neonatal septicemia and pneumonia
include Escherichia coli and Staphylococcus epidermidis and
S. aureus. In hospitals Klebsiella pneumoniae is an important
etiological agent.
Clinical Features
The newborn baby has a limited ability to respond to a
number of insults resulting in identical stereotyped
manifestations due to a variety of conditions. The manifestations of neonatal septicemia are often vague and
nonspecific demanding high index of suspicion for its
early diagnosis. Any alteration in the established feeding
behavior is the most characteristic early feature. The baby

73

who had been active and sucking normally, gradually

or suddenly becomes lethargic, inactive, unresponsive
and refuses to suck. The infant may appear pale with
grayish circumoral cyanosis and a vacant look. Hypothermia is a common manifestation of septicemia in
preterm babies, while term babies may manifest with
fever, especially in association with gram-positive infections and meningitis. Diarrhea, vomiting and abdominal
distention may occur. Jaundice and hepatosplenomegaly
may be present. Episodes of apneic spells with cyanosis
may be the sole manifestation of septicemia in preterm
babies.
The additional localizing features may appear depending upon the spread of infection to different systems
and organs of the baby. The clinical manifestations of
pneumonia include tachypnea, chest retractions, grunting, cyanosis and apneic spells in addition to inactivity
and poor feeding. Cough is unusual. Findings on auscultation of chest are nonspecific and noncontributory.
Diagnosis
Septic screening should be done to support the clinical
suspicion of infection before the institution of specific
antibacterial therapy. The reliable markers of neonatal
septicemia include leukopenia (less than 5000 per cu
mm), elevated band neutrophils (more than 20%), raised
micro-ESR (more than 15 mm) and positive C-reactive
protein (more than 8 mg per ml). Blood culture and CSF
examination are mandatory before initiating specific
antibacterial therapy. A skiagram of the chest should be
taken in all cases. It may show scattered or localized
opacities suggestive of patchy consolidation. Blood
should be examined for glucose, bilirubin, urea and
electrolytes. In all infants born following PPROM (more
than 24 hours) or those developing respiratory distress
soon after-birth, gastric aspirate should be collected in a
heparinized tube and examined under the microscope
after staining with Leishman's stain. The presence of
more than 5 neutrophils per high power field or when
their number exceeds three times the number of the
epithelial cells, is suggestive of intrauterine or congenital
pneumonia. A bacterial culture should be obtained from
liquor amnii (or cervical swab), gastric aspirate, throat,
umbilical stump and blood.
Management
The infant should be managed in a thermoneutral
environment and started on intravenous infusion.

74 IAP Textbook of Pediatrics

Hypoglycemia, anemia and shock should be appropriately managed. Fresh blood or fresh frozen plasma is
useful to improve defense mechanisms by providing
opsonins, complement and polymorphonuclear leukocytes. Specific antibacterial therapy should be instituted
through intravenous route. The choice of antibiotics
depends upon the prevalence of bacterial flora and their
sensitivity pattern against available antibiotics. In a
community-acquired neonatal septicemia, a combination
of ampicillin or benzyl penicillin with gentamicin is
appropriate. In hospital-acquired neonatal septicemia,
the logical initial choice would be a combination of
cloxacillin with aminoglycoside such as gentamicin or
amikacin. When response to this antibiotic combination
is unsatisfactory or there is an associated meningitis,
ampicillin is substituted by a third generation cephalosporin such as cefotaxime. When the etiologic agent is
identified, the antibacterial therapy can be made highly
specific. For instance, septicemia due to Pseudomonas
aeruginosa is best managed by ceftazidime or piperacillin
and in resistant staphylococcal infection, amoxycillin
with clavulinic acid or vancomycin may be considered.
Listeriosis is best managed with ampicillin.
Exchange blood transfusion is recommended in
critically sick neonates having sclerema, disseminated
intravascular coagulopathy (DIC) or hyperbilirubinemia.
There is no role of intravenous immunoglobulins in
neonatal sepsis. The prognosis depends upon the weight
and maturity of the infant, nature of the etiologic agent
and quality of specific and supportive therapy. The
presence of underlying congenital malformations like
meningomyelocele, tracheoesophageal fistula and
surgical procedure adversely affect the outcome. The
reported case fatality rates due to neonatal septicemia in
various studies from India range between 15 and 20
percent. Therefore, it is essential that all efforts should
be made to prevent the occurrence of bacterial infections
in newborn babies by adopting strict aseptic rituals and
routines.
Prevention of Infections
Newborn babies especially those prematurely born are
at an increased risk of developing bacterial infections and
despite aggressive management septicemia has a high
case fatality rate. It is far more cost-effective to prevent
nosocomial infections rather than to treat them with
expensive antibiotics and high quality supportive care.
The following protocols for prevention of infections
should be strictly followed in the nursery.

1. Handwashing and thorough scrubbing with soap and

water up to elbows for at least 2 minutes, gowning
and change of shoes are mandatory before entry to
the nursery. Rings, bangles and wristwatch should
be removed before hand-washing. Strict and
obsessive handwashing (for 20 seconds) and use of
antiseptic lotion in-between handling of babies
should be ensured. The hands should be dried with
either a disposable paper napkin (or reusable
autoclaved minitowel) or hand dryer.
2. Babies should be fed early and exclusively with
expressed breast milk (or breastfeed) without any
prelacteal feeds. Careful attention should be paid to
the hygiene of the katori and spoon. The use of a
feeding bottle and pacifier are condemned.
3. The umbilical stump should be left open. Local
application of triple dye or spirit reduces colonization.
4. All procedures in the nursery should be performed
after wearing mask and gloves. Unnecessary invasive
interventions such as needle pricks and setting up of
intravenous lines should be kept to the barest
minimum. The use of stock solution of heparinized
saline for rinsing of intravenous lines is a dangerous
practice and should be replaced by flushing with a
single-use normal saline ampule. There should be no
compromise in the use of disposables. Barrier nursing
should be ensured.
5. Strict housekeeping routines for washing, disinfection, cleaning of cots/incubators, etc. should be
ensured, and these policy guidelines should be
available in the form of a manual in the nursery.
6. The use of prophylactic antibiotics for prevention of
nosocomial infections is strongly condemned. They
are not only useless but dangerous due to the
potential risk of emergence of resistant strains of
bacteria.
Neonatal Jaundice
Jaundice is a relatively common physical abnormality in
a newborn baby during the first week of life. Clinical
jaundice manifests as yellowness of the skin of the face
when the serum bilirubin level exceeds 5 mg/dl. As the
degree of jaundice increases, there is a cephalopedal
progression of yellowness of the skin. When the trunk of
the baby is distinctly yellow stained, the serum bilirubin
level is likely to range between 10 and 15 mg/dl. The
yellow staining of the palms and soles is ominous and
indicates that the serum bilirubin level has exceeded

Newborn Care
TABLE 3.6.1: Causes of pathological jaundice
1. Idiopathic
2. Prematurity
3. ABO-incompatibility (ABO-HDN*)
4. Rh-isoimmunization (Rh-HDN*)
5. G-6-PD deficiency
6. Septicemia
7. Breast milk jaundice
8. Hypothyroidism

75

limits of intensity and age of disappearance besides the

exclusion of pathologic causes. Physiological jaundice
occurs due to relative polycythemia with reduced
lifespan of neonatal red blood cells, hepatic immaturity
(regarding uptake, conjugation and excretion of bilirubin)
and exaggerated enterohepatic circulation of bilirubin.
The mother must be reassured regarding the benign
nature of physiological jaundice and her fears regarding
infection or hepatitis should be allayed. She should be
advised to breastfeed the baby frequently, but there is
no need to advise extra glucose water.

9. Neonatal hepatitis (intrauterine infections)

10. Metabolic disorders

Hemolytic Disease of the Newborn (HDN)

* HDNHemolytic disease of the newborn

Hemolytic disease of the newborn (HDN) due to blood

group incompatibility between the mother and fetus is
the most common cause of hyperbilirubinemia in the
newborn baby. The incompatibility may exist among
Rhesus, ABO or minor blood group systems.

15 mg/dl. All newborn babies must be examined twice

a day during the first week of life to assess the onset,
severity and age of disappearance of jaundice.
Causes of Jaundice
The important causes of pathological jaundice in
newborn babies are given in Table 3.6.1. About 5 percent of newborn babies develop pathological jaundice
or hyperbilirubinemia. The onset of jaundice within 24
hours of age, its marked intensity as evidenced by yellow
staining of the palms and soles and its persistence beyond
two weeks of age are suggestive of pathological jaundice.
Investigations should be performed to identify possible
cause of pathological jaundice and appropriately
managed.
Physiological Jaundice
About 60 to 70 percent of healthy newborn babies are
likely to develop physiological jaundice which may cause
undue anxiety to the parents. Physiological jaundice
appears between 24 and 72 hours of age, its maximum
intensity is seen on the 4th to 5th days of life, and the
peak serum bilirubin level does not exceed 15 mg/dl.
This type of jaundice usually disappears before 14 days
of life and does not need any specific therapy. In preterm
babies, the peak of physiological jaundice is seen a little
later, and peak bilirubin level may be higher and jaundice
takes relatively longer time to disappear. The diagnosis
of physiological jaundice cannot be made by examining
the baby at one point of time because it depends upon a
characteristic time table of jaundice, taking into
consideration the time of onset of jaundice, maximal

Rhesus Hemolytic Disease of

the Newborn (Rh-HDN)
When an Rh-negative mother is carrying an Rh-positive
fetus, the passage of fetal red blood cells into the maternal
circulation may invoke an antibody response by the
maternal immunological system. Enough anti-D
antibodies are not produced during the first pregnancy,
but each subsequent pregnancy with Rh-positive fetus
leads to increasing antibody production. The Rhsensitization of the other may also occur by amniocentesis, external version, abortion and stillbirths. The
anti-D antibodies being IgG in type, they readily
crossover to the fetus through the placenta and destroy
D-positive fetal red blood cells. The Rh isoimmunization
can be suspected during antenatal period by identifying
the blood group of the mother and estimating the titer of
anti-D antibodies by indirect Coombs test.
There is a wide spectrum of clinical manifestations
of erythroblastosis due to Rh-HDN, ranging from a
normal baby to a stillborn baby with hydrops fetalis.
There is increasing severity of the disease with each
subsequent pregnancy. The newborn baby may be
anemic at birth and has hepatosplenomegaly. Jaundice
usually appears within 24 hours of age and rapidly
increases in intensity. In a severely affected baby, the
clinical picture is characterized by severe anemia, gross
hepatosplenomegaly and generalized anasarca (hydrops
fetalis), and the baby may die in utero.

76 IAP Textbook of Pediatrics

If the mother is Rh-negative, cord blood should be
collected for Rh and ABO typing, direct Coombs test,
hemoglobin, reticulocyte count, peripheral blood smear
and serum bilirubin. The positive direct Coombs test in
a Rh-positive baby clinches the diagnosis of Rh-HDN.
In the affected baby, the serum bilirubin should be
monitored every 6 to 12 hours depending upon the rate
of rise of bilirubin.
Rhesus isoimmunization can be effectively prevented by prophylactic administration of anti-D immunoglobulins in an unsensitized Rh-negative woman
within 72 hours of delivery in the following situations:
1. Delivery of an Rh-positive baby
2. Abortion or stillbirth of Rh-positive conception
3. Following procedures having increased risk of
fetomaternal hemorrhage such as amniocentesis and
external version.
The dose of anti-D immunoglobulin varies. The antiD immunoglobulin should only be given to the mother
whose indirect Coombs' test is negative.
ABO Hemolytic Disease of the Newborn (ABO-HDN)
The ABO hemolytic disease of the newborn usually
occurs when mother is O group and her baby is either A
or B group. Fetomaternal ABO incompatibility exists in
about 25 percent of pregnancies, but the hemolytic
disease develops in only 10 percent of these incompatible neonates. Unlike Rh-HDN, the history of increasing
severity of disease in subsequent pregnancies is generally
not present in ABO-HDN.
The diagnosis of ABO-HDN is suspected by early
onset of jaundice in A or B group baby of an O group
mother. The ABO-HDN is a relatively milder disease as
compared to Rh-HDN. The anemia is usually absent or
mild, and there may be mild hepatosplenomegaly. The
direct Coombs test is usually negative or weakly positive.
Blood examination may show reticulocytosis, microspherocytosis and increased fragility of red blood cells.
The diagnosis is confirmed by the demonstration of high
titer of IgG hemolysins in maternal blood against the
baby's blood group.
Septicemia
Jaundice is an important manifestation of bacterial infection in newborn babies and occurs due to hemolysis and
hepatitis. The clinical picture is usually dominated by

systemic features of septicemia and the occurrence of

jaundice after the age of three days. The direct reacting
or conjugated bilirubin is often elevated to 2.0 mg/dl or
more, and jaundice often persists beyond 14 days of life.
Glucose-6-PhosphateDehydrogenase Deficiency
The incidence of G-6-PD deficiency varies between 5 and
20 percent among different ethnic groups in India.
Deficiency is limited to male babies as the condition is
inherited as X-linked recessive. The hemolysis may occur
spontaneously or following exposure to certain drugs
and infections. The clinical picture is characterized by
the sudden and dramatic appearance of unconjugated
hyperbilirubinemia requiring exchange blood transfusion.
Persistent Neonatal Jaundice
Neonatal jaundice whether physiological or pathological,
usually disappears by 2 weeks of age. The important
causes of persistent neonatal jaundice are illustrated in
Table 3.6.2. Hyperbilirubinemia may be predominantly
unconjugated or there may be significant elevation of
direct reacting or conjugated bilirubin. The elevation of
conjugated bilirubin is usually characterized by clay
colored stools, and high colored urine staining the
napkins. It must be remembered that most conditions
producing hyperbilirubinemia during the first week of
life are associated with the elevation of unconjugated
bilirubin. Despite deep jaundice, the urine in such babies
is normal colored and does not contain any bile pigments
or urobilin.
TABLE 3.6.2: Causes of persistent neonatal jaundice
Unconjugated hyperbilirubinemia
1. Breast milk jaundice
2. Hypothyroidism
3. Crigler-Najjar syndrome
4. Intestinal obstruction or stasis
5. Ongoing hemolysis (Rh, ABO)
Conjugated hyperbilirubinemia (cholestasis)
1. Neonatal hepatitis
2. Extrahepatic biliary atresia
3. Inborn errors of metabolism
4. Total parenteral nutrition

Newborn Care
Pathogenesis of Kernicterus
Jaundice in a newborn baby is a serious condition because
unconjugated hyperbilirubinemia may cause bilirubin
encephalopathy or kernicterus. The occurrence of
kernicterus is related to complex interaction between the
level of unconjugated bilirubin which is lipid soluble,
gestational maturity of the infant and integrity of the
blood-brain barrier. It is generally believed that
unconjugated bilirubin level of more than 20 mg/dl due
to any cause may lead to kernicterus in a newborn baby.
However, it is well-known that a preterm infant may
develop brain damage at a relatively lower serum
bilirubin level, while some term babies may tolerate
serum bilirubin concentration of up to 30 mg/dl without
any kernicterus. Adequate levels of serum proteins are
essential for effective binding of bilirubin to prevent its
leakage into the interstitial and intracellular compartments. When bilirubin binding sites in the albumin are
blocked by other anions like hydrogen (acidosis), free
fatty acids, (hypoglycemia and hypothermia) and certain
drugs like salicylates, sulfonamides and sodium
benzoate, kernicterus may occur at lower serum bilirubin
levels. Perinatal distress factors such as hypoxia,
hypothermia, hypoglycemia, acidosis, birth injury and
septicemia may damage the integrity of the blood-brain
barrier, and predispose the infant to develop bilirubin
encephalopathy at a relatively lower serum bilirubin
levels.

77

preparation of vitamin K in high doses is known to

aggravate hemolysis and may predispose to the
development of kernicterus. Administration of phenobarbitone during the last week of pregnancy in an Rhisoimmunized mother or during first three days of life
in any infant suspected to have Rh-HDN and cephalhematoma may reduce the severity of jaundice by
enhancing maturation of hepatic microsomal enzymes
like Y-acceptor proteins and glucuronyl transferase in
the liver. Its therapeutic utility, howerver, is limited
especially in preterm babies. High dose intravenous
immunoglobulin (0.5-1.0 gm/kg) in Rh-iso-immunized
babies is known to decrease need of exchange blood
transfusion and duration of phototherapy.
Phototherapy
Phototherapy or exposure to light is known to cause
photoisomerization of bilirubin to more polar, watersoluble, harmless compounds which are readily excreted
in the bile, feces and urine. Phototherapy units with blue
or white tubes or halogen lamps are useful for preventing
rapid rise in serum bilirubin levels (Fig. 3.6.1). The naked
infant is exposed under phototherapy unit which is kept
at a distance of about 45 cm from the baby's skin. During
exposure to light, the eyes must be effectively shielded
to prevent retinal damage. The position of the infant
should be changed frequently so that the maximal area
of the skin is exposed to light. The infant is kept under
the light round-the-clock and taken out only for feeding

Management
Hyperbilirubinemia should be considered as a medical
emergency, and all attempts must be made to ensure that
serum bilirubin levels are kept within safe limits.
Exchange blood transfusion remains the most effective
and reliable method of lowering serum bilirubin when
it approaches critical levels. Other supportive measures
are useful to prevent excessive rise of serum bilirubin.
Supportive Measures
Early feeding and the maintenance of adequate hydration
are useful to prevent hyperbilirubinemia. Hypoxia,
hypothermia, hypoglycemia and acidosis should be
prevented and if they occur they should be promptly
managed. Septicemia should be treated with appropriate
antibiotics. When cephalhematoma is associated with
critical hyperbilirubinemia, it should be aspirated or
drained. The administration of a water-soluble

Figure 3.6.1: Compact fluorescent light phototherapy units (top

both sides) and fibreoptic cold light below the baby for giving
intense phototherapy for jaundice. Note eyes are effectively
covered to prevent retinal damage

78 IAP Textbook of Pediatrics

or change of wet napkins. Most preterm babies are placed
under phototherapy when their serum bilirubin
approaches 10 to 12 mg/dl, and term babies are given
phototherapy when their serum bilirubin approaches
15 mg/dl. Appropriate charts are available which are
based on serum bilirubin levels, postnatal age of the
infant and birth weight of the child, to provide more
reliable indications for phototherapy and exchange blood
transfusion. During phototherapy the infant should be
closely watched for hydration status, temperature, degree
of jaundice and anemia by frequent blood examination.
Phototherapy is by and large safe but may produce loose
greenish stools, dehydration, hypothermia, or hyperthermia, and skin rash. During phototherapy, the clinical
evaluation of the severity of jaundice becomes unreliable
because the infant's skin gets bleached under light.
Exchange Blood Transfusion
If despite phototherapy and other supportive measures,
the bilirubin level is approaching 20 mg/dl, exchange
blood transfusion is mandatory to prevent brain damage.
The indications for exchange blood transfusion are listed
in Table 3.6.3. However, in an individual infant, the
decision for exchange blood transfusion should not be
based merely on the level of unconjugated serum
bilirubin but other important factors like gestational
maturity, postnatal age, presence or absence of perinatal
distress factors, and cause of jaundice should also be
taken into consideration. Double volume (160 ml/kg
blood) exchange blood transfusion is performed through
umbilical vein.
BIBLIOGRAPHY
1.

Arya LS, Singh M. Gastric aspirate shake test as a

predictor of hyaline membrane disease. Indian J Med Res
1979;70:444.
2. Deorari AK, Chellani H, Carlin JB, Greenwood P, Prasad
MS, Satyavani A, et al. Clinico-epidemiological profile
and predictors of severe illness in young infants
(<60 days) reporting to a hospital in North India. Indian
Pediatrics 2007;44:739-48.

TABLE 3.6.3: Indications for exchange

blood transfusion
Early indications in infants with Rh-HDN
1. Cord hemoglobin of 10 g/dl or less
2. Cord bilirubin of 5 mg/dl or more
3. Unconjugated serum bilirubin of more than 10 mg/dl
within 24 hours or rate of rise of more than 0.5 mg/dl
per hour
Jaundice due to any cause
1. Exchange at lower bilirubin levels in the presence of
perinatal distress factors (Asphyxia, respiratory distress,
sepsis, hypothermia, etc.)
2. Unconjugated serum bilirubin of 20 mg/dl or more in a
term baby
3. In preterm babies, serum bilirubin of more than 1.0 mg/
100 g weight of the infant (i.e., 10 mg/dl for 1000 g and
15 mg/dl for 1500 g and so on)

3.
4.
5.

6.
7.

8.
9.
10.
11.
12.

Diamond I. Kernicterus. Revised concepts of pathogenesis and management. Pediatrics 1966;38:539.

Gluck L, Kulovich HV, Borer RC, et al. Diagnosis of the
respiratory distress syndrome by amniocentesis. Am J
Obstet Gynecol 1997;109:440.
Gottstein R, Cooke RW. Systematic review of intravenous
immunoglobulin in hemolytic disease of the newborn.
Arch Dis Child Fetal Neonatal 2003;88:F6-F10.
Jeeva Sankar M, Agarwal R, Deorari AK, Paul VK. Sepsis
in the newborn. Indian J of Pediatrics 2008;76:261-66.
Kishore K, Deorari AK, Singh M, et al. Early-onset neonatal sepsis: Vertical transmission from maternal genital
tract. Indian Pediatr 1987;24:45.
Mishra S, Agarwal R, Deorari AK, Paul VK. Jaundice in
the newborns. Indian J of Pediatr 2008;75:157-63.
Newman TB, Maisels MJ. Bilirubin and brain damage:
what do we do now? Pediatrics 1989;83:1062.
Paul VK, Singh M. Diagnosis and treatment of neonatal
sepsis. Indian Pediatr 1986;23:1023.
Singh M. Some practical aspects of neonatal jaundice.
Indian J Pediatr 1977;44:220.
Starr SE. Antimicrobial therapy of bacterial sepsis in the
newborn. J Pediatr 1985;106:1043.

4.1 Growth and Development: Basic Concepts: AB Desai, Dilip Mukherjee ......................................................................................... 80
4.2 GrowthBirth to Puberty: KN Agarwal, DK Agarwal, SK Upadhyay ................................................................................................. 83
4.3 Physical Growth and Sexual Development in Adolescence: KN Agarwal, DK Agarwal, SK Upadhyay ....................................... 96
4.4 Development: KN Agarwal, DK Agarwal, SK Upadhyay ..................................................................................................................... 105
4.5 Failure to Thrive: Madhulika Kabra, PSN Menon ................................................................................................................................ 111

80 IAP Textbook of Pediatrics

4.1 Growth and Development: Basic Concepts

AB Desai, Dilip Mukherjee
Growth and development begin at conception and end
at maturity. They are unique characteristics of children
and any obstacle in this process at any stage can possibly
result in aberration of growth and/or development.
Frequently, the terms growth and development are used
together. In the normal child they progress together, and
are interdependent. Growth is defined as an increase in
the size of an individual due to increase in number and
size of the cells, resulting in an overall increase. This
increase can be seen, appreciated and measured
accurately.
ASSESSMENT OF GROWTH
Growth can be measured in terms of:
i. Nutritional anthropometry (weight, height, circumference of head, chest, abdomen and pelvis)
ii. Assessment of tissue growth (skin fold thickness and
measurement of muscle mass)
iii. Bone age (radiological by appearance and fusion
of the various epiphyseal centers)
iv. Dental age
v. Biochemical and histological means.
For day-to-day work anthropometry is the simplest
tool.
Nutritional Anthropometry
This is the technique of measuring somatic growth.
Length
Until 24 or 36 months of age, length in recumbency is
measured using an infantometer (See Chapter 2.2 on
Physical Examination for details). The length is recorded
in centimeters upto one decimal point.
Height
After the age of 2 years, standing height is recorded by a
stadiometer. The details have been provided in the
Chapter 2.2 on Physical Examination. Detecto weighing
scales fixed with anthropometric rods are in common
use. For community survey, portable type of anthropometric rods are also used. For recording stature (height),

the subject should remove his/her socks and shoes and

stand perfectly straight with arms relaxed by his/her sides
and ankles and knees together. Before measurement starts,
a gentle pressure may be applied over the spine with one
hand while other hand holds the anthropometric rod. The
subjects head is positioned in Frankfort plane.
Sitting Height
For recording sitting height, the subject is made to sit on
a table or other convenient hard surface so that his/her
head lies in Frankfort plane. The back should be straight,
thighs horizontal and comfortably positioned. The feet
should be supported on the foot board and hands should
rest comfortably on the subjects lap. To ensure that the
subject's back is fully extended, the observer may run
his/her index finger up the spine applying pressure to
the lumbar and sacral regions, causing the subject to sit
up a reflex action. The head board should be lowered
and made to touch the head of the subject and reading
should be recorded to the nearest completed unit.
Body Proportions
The total body length is divided in two segments. The
upper segment is from head to pubic symphysis and
lower segment from pubic symphysis to the toes. The
U/L segment ratio is 1.7:1 at birth. By 6 to 7 years, it
reaches 1:1. If the ratio is infantile after 1 year of age, it
suggests short limb dwarfism due to bone disorders such
as rickets and hypothyroidism.
Weight
It is the commonest and important anthropometric
measurement. The weighing scales best suited are those
which are designed on balance arm principle. The details
of measurement have been provided in Chapter 2.2 on
Physical Examination. Accuracy up to 0.1 kg is quite
acceptable. For smaller babies, machines of more
accuracy are required as 0.1 kg forms a higher percentage of total body weight. More recently, many electronic
weighing scales giving accuracy up to 0.01 kg have been
made available.

Growth and Development

The weighing scales should be checked for
accuracy using known weight from time to time. The
beam scales are better instruments for all purposes rather
than spring weighing scales, i.e. bathroom scales, as the
spring may get expanded due to repeated use, may get
rusted and variation of temperature may give false
reading.
In Japan special type of weighing scales are devised
which in addition to the weight of an individual also note
Body Mass Index and amount of subcutaneous fat.
Head Circumference
The details of measuring head circumference has been
given in Chapter 2.2 on Physical Examination. It should
be recorded to the nearest 0.1cm.
Midarm Circumference (MAC)
The details have been provided in the Chapter 2 on
Physical Examination. It should be kept in mind, that
upper arm circumference can be measured both in flexed
and extended positions and also either at the maximum
circumference of biceps muscle or mid-point, as the
difference between the two is negligible.
Chest Circumference
The chest circumference for boys, prepubertal girls and
men can be recorded at the level of xiphisternal junction
during normal breathing. It is recorded to the nearest
0.1 cm.

81

can be used to distinguish between malnutrition of recent

origin, i.e. wasting and malnutrition due to a considerable
period of months. In chronic malnutrition the child is
stunted with the weight for age and height for age being
low. In acute malnutrition, height for age is normal but
weight for age is low (wasting). Thus, the weight and height
measurements together are useful in understanding the
dynamics of malnutrition. In nutritional short stature the
weight/height is equal; the child may pass off as a normal
child of lower age if the chronological age is not known.
These have been discussed in the chapter on Protein-energy
malnutrition.
Quackstick
Quakers midarm circumference measuring stick is a
height measuring rod, calibrated in MAC rather than
height; values of 80 percent MAC for height are marked
on the stick at corresponding height levels. If a child is
found taller than his/her arm circumference level on the
stick, he/she is considered malnourished. The quackstick
was devised in Mexico and has since been adapted in
Africa and India.
Midarm/Head Circumference Ratio
It is a simple and useful criterion for detection of
malnutrition. A ratio 0.280 to 0.314 indicates early malnutrition, 0.250 to 0.279 moderate, and less than 0.249
denotes severe malnutrition.

Age Independent Anthropometry

Quetlets Index
Midarm Circumference (MAC)
As the midarm circumference is relatively constant
between 16.5 cm to 17.5 cm in 1 to 5 years of age, this
measurement may be considered as an age independent
variable up to 5 years of age. Any child whose MAC is
less than 12.5 cm up to 5 years of age, is considered
malnourished. Shakirs tape also measures the MAC. A
bangle of 4 cm in diameter, used in field studies is not a
reliable method (Bangle test).
Weight for Height
The degree of wasting can be measured by comparing the
childs weight with expected weight for a healthy child of
the same height. Combinations of these measurements
have been used to distinguish different types of
malnutrition. Waterlow suggested that weight for height

It is based on the relationship between weight and height

and is expressed as weight (kg)/Height (cm) 100.
Normal value varies from 0.14 to 0.16. In gross
malnutrition, it is less than 0.14. It is a quite reliable ratio
for assessing malnutrition.
Mid-upper Arm/Height Ratio
It is also a very good indicator of nutritional status. A
ratio of less than 0.29 indicates gross malnutrition, while
the normal value ranges from 0.32 to 0.33.
Body Mass Index (BMI)
BMI =

Weight (kg)

_________________

Height2(m2)

82 IAP Textbook of Pediatrics

This is similar to Quetlets index except that the values
are in SI units. BMI values can be used to draw standardized percentile curves in children and adolescents. It is
specially useful for defining obesity. BMI values above
95th percentile for age are usually used to define obesity.
Ponderal Index (PI)
PI =

Height (cm)

______________________________________

Cube root of body weight (kg)

This is another index similar to BMI and is often used

in defining newborn with intrauterine growth retardation (IUGR).

caliper is applied at the marked level and reading is

recorded to 0.1 mm.
Bone Age or Skeletal Maturity
Appearance and fusion of various epiphyseal centers
follow a definite sequence related to chronologic age from
birth to maturity. Radiological examination of left wrist
and elbow is usually considered for bone age assessment.
X-ray of the lower end of femur, and talus is used for the
assessment of maturity of new-born babies. The details
of appearance and fusion of various centers is given in
subsequent sections.
Dental Development

Tissue Growth
This measurement is done for special purposes and is
not used in routine clinical practice. It is measured with
a special caliper.
Triceps Skinfold Thickness
The skinfold is picked up over the posterior surface of
the triceps muscle, 1 cm above the mark on a vertical
line passing upward between bony point identified for
taking measurement, maintaining a pressure of 10 g/
mm2 on the caliper and freeing the skinfold from the
underlying muscle with left hand between thumb, index
and middle finger and holding caliper with the other
hand. The reading is recorded to the nearest 0.1 mm.
Subscapular Skinfold Thickness
The subject stands as for the triceps skinfold with
shoulder and arm relaxed. The inferior angle of scapula
is located by running finger on medial border of scapula
downward, till inferior angle is reached. The skin is
pinched up immediately below the inferior angle either
in vertical line or slightly downward and reading is
recorded to the nearest 0.1 mm maintaining pressure of
caliper as before.
Biceps Skinfold Thickness
For recording biceps, the child is made to stand erect,
facing observer with arm on side and palm facing
forward. The skinfold is picked up over the belly of biceps
and 1 cm above the line marked for the upper arm
circumference and triceps skinfold on a vertical line
joining antecubital fossa to the head of humerus. The

Eruption of teeth follow a definite sequence. Eruption of

temporary or deciduous teeth begins at about
6 months with eruption of upper or lower central incisors,
followed by lateral incisor. By one year of age 4 to 8 teeth
are present. The permanent teeth begin to erupt at 6 years.
Details of dental development are provided in
subsequent chapters.
GROWTH STUDIES AND PERCENTILES
While discussing growth, various terms which are used
must also be understood.
Cross-sectional Study
This is a very convenient, easy, less time consuming and
economical method to study growth. For example,
children of each age group in large number are collected, their weights are recorded and an average is found
out. These groups of children are studied just once.
Linear or Longitudinal Study
In this type of study, the same child is measured from
birth to maturity at yearly or previously decided regular
intervals. It is difficult to study very large number of
children in this fashion and hence, the linear studies have
comparatively less subjects in number. The longitudinal
study helps us to determine the growth velocity.
Concept of Percentiles
While making various calculations, the use of terms like
mean or average and standard deviation (SD) is well
known. While expressing the growth the term percentile
or centile is often used. This may be explained in a simple

Growth and Development

way, e.g. the height of 100, one year old normal children is
not exactly the same. They are arranged in such a way
that the shortest is number one and the tallest is number
100. Rows of children are thus made. The mean of each
number is worked out. The child at number 1 is one
percentile, number 10 is 10th centile, number 50 is 50th
centile and so on. The child on 10th centile on height
chart means that 9 children are less in height and 90
children are more in height. The 50th centile is the median
value and is also termed the standard value. Accepted
range for normal is between 3rd and 97th percentiles.
The standard deviation (SD) charts are based on
distribution of data above and below a mean value. The
average normal range falls above and below 2 SD,
expressed as 2 SD. + 1 SD is equal to 84 centile and-1 SD
is equal to 16th centile. + 2 SD corresponds to 97th centile
and - 2 SD corresponds to 3rd centile. The mean SD
curves are useful for quantifying the degree of retardation
exactly.

charts are separate for boys and girls. The recently

developed Indian standards are provided in subsequent
sections.
Velocity Growth Charts
These charts are developed by long-term longitudinal
studies and are known as incremental charts. They show
the rate of change which could be due to chronic illness
or growth hormone deficiency. Different countries may
use their own growth charts. In Great Britain, Tanner's
growth charts are used. In India, Agarwal et al have
prepared the charts based on studies on affluent Indian
children.
BIBLIOGRAPHY
1.

2.

Growth Charts
Growth chart is the most important tool in assessment
of growth of an individual child. A standard chart
contains weight for age, height for age and weight for
height. The head circumference is included for first 3
years of life. They depict mean, standard deviation (SD)
or percentile values at each age.
World Health Organization (WHO) has accepted
National Center for Health Statistics (NCHS) USA, charts
as the international standard for growth for the first 3
years of life. The growth of the healthy and wellnourished children is represented in these charts. The

83

3.
4.
5.
6.
7.

Agarwal DK, Agarwal KN, Upadhyay SK, Mittal R,

Prakash R, Rai S. Physical and sexual growth pattern of
affluent Indian children from 5 to 18 years of age. Indian
Pediar 1992;29:120383.
Agarwal KN. Physical growth in Indian affluent
children (Birth to 6 years). Indian Pediatr 1994;31: 377
413.
Falknar F, Tanner JM (Eds). Human Growth, 2nd edn, 3
vol. New York: Planum. 1986.
Mukherjee D, Nair MKC. Growth and development.
Growth and Development 1st edn. IAP, 1997.
Tanner JM. Growth at Adolescence, 2nd edn. Oxford:
Blackwell Scientific Publication 1962.
Tanner JM. Physical growth and development. In :Forfar
JO, Arneil GC (Eds): Textbook of Pediatrics, 2nd edn.
London : Churchill Livingstone 1978;249303.
Tanner JM, Whitehouse RH, Camerson N et al. Assessment of Skeletal Maturity and Prediction of Adult Height,
2nd edn. London: Academic Press. 1983.

4.2 GrowthBirth to Puberty

KN Agarwal, DK Agarwal, SK Upadhyay
DEFINITION
Growth and development in human beings at the moment
of conception and are continuous processes, until the
epiphyses (growing ends of bones) fuse and growth in
height ceases. The term growth denotes increase in size or
body mass; and development is the emerging and expanding
capacities of an individual to provide progressively greater

faculties in functions, i.e. acquisition of a variety of

competencies for optimal functioning in a social milieu.
The growth, measures show how body grows, i.e.
length (growth in stature), skull circumference (brain
growth) and weight (bone and muscle mass) increase
rapidly in early childhood-first three years of life( the
most active growth period). Therefore, regular measurements of length (best indicator of physical growth) and

84 IAP Textbook of Pediatrics

skull circumference (indicator of brain growth) are
important to detect growth failure (Figs 4.2.1 and 4.2.2;
Table 4.2.1).

TABLE 4.2.1: Growth pattern in infant and

early childhood
Length gain being the best indicator of growth
Length gain

Measurement at age

At birth
Birth to 3 months
36 months
69 months
912 months

3.5 cm/month
2.0 cm/month
1.5 cm/month
1.3 cm/month

3 months
9 months
12 months
24 months

50 cm
60 cm
70 cm
74-75 cm
86-87 cm

By 3rd year (36th month length is 93 cm). At 4th year approaches

100 cm.
Weight
Weight at birth 3.03.5 kg, there is loss of around 810 percent
in first 810 days by 1215th days it approaches the birth weight.
Weight gain

Measurement at age

2 weeks to 3
months
36 months

25 g/day
20 g/day

69 months

15 g/day

912 months

12 g/day

Doubles birth weight

by 56 months
Trebles (3 times) at 1 year of
age
Quadruples (four times) at
2 years of age. Five time by
3 years of age and 6 times by
5 years of age

By the time infant wt. doubles birth weight~ 5-6 months; fat in
body trebles (25% of the total body weight) thus almost 1.5 kg
body weight at 6 months is fat, while during 6-12 months-fat
deposit is 500 g, only.
Skull(Head Circumference): Indicates Brain Growth
Growth in head circumference (cm): In normal full term child
Age

Head circumference

At birth
3 months
6 months
9 months
12 months
2 years
5 years
12 years

34-35
40
42-43
44-45
46-47
48
50.3
52 cm

Increment is 2 cm/mo in first 3 mo; 1 cm/mo between 3 to 6 mo;

0.5 cm/mo between 9-12 mo. Thereafter gain in head circumference is very slow, only 5 cm after first birth day to 12 years of
age.
Head Circumference (HC) in Preterm
Gestation weeks
HC cm

26
24.0

27
25.6

30
27.6

32
29.6

34
31.6

36
33.0

Postnatal growth, i.e. increase in length/height, skull

circumference and weight, stretches from i) Conception:
Intrauterine growth period to infancy (the most rapid
growth period. Brain growth is very rapid from 20 weeks
of gestation, and continues until 20 months of age, It is
around 67%, of the adult size at birth and 90%, on the
first birthday (Fig 4.2.3; Tables 4.2.1 and 4.2.6). These
cerebellum (meaning Little Brain in Latin, it plays a big
part in the integration of sensory perception and motor output)
reaches adult size by 18 months of age.
Growth in Preschool and School Years
This rapid early childhood growth is followed by a long
phase of slow juvenile growth the height gain is: in early
school Years, by 3-5 years of age the height increment is 68 cm/year and weight gain is 2 kg / year. Later in school
age 6 to 10 years in girls and 6- 12 years in boys
(Prepubescent) 5-6 cm per year and weight 3-3.5 kg per
year, until pubescence sets in (Table 4.2.2 and Figs 4.2.4
and 4.2.5).
Growth in Adolescence
The morphological and physiological changes during
Adolescent Growth Spurt involve nearly all organs of
the body. These changes do not begin at the same age
point or take the same length of time in all individuals to
reach completion. During Puberty somatic as well as
skeletal growth is related to sexual development (sexual
maturity rating by Tanner 1962), as adolescent growth is
initiated and controlled by the sex hormones. Thus for
assessment of their growth means for height, weight,
BMI, skin fold thickness etc. in relation to sexual maturity
are more relevant than those obtained for chronological
age (Agarwal et al Indian Pediatrics, 2001).
Around 10-12 years in girls and 12-15 years in boys
there is initiation of puberty- adolescent growth spurt
lasting for 2.5 to 3.0 years. In this phase girls gain 25-26
cm and boys 28-30 cm