A Manual of Essential Pediatrics-Meharban Singh

Introduction to Pediatrics1“We are guilty of many errors and many faults. But our worst crime is abandoning the children, neglecting the foundation of life. Many of the things we need can wait, the child cannot. Right now is the time his bones and fl esh are being formed, his blood is being made. And his senses are being developed. To him we cannot answer tomorrow. His name is TODAY.”

– Gabriela Mistral

1.1 Goal of Child Care

The basic aim and goal of pediatricians is to ensure that every child is assisted to achieve his or her optimal genetic potential for physi-cal growth and mental development. The spec-trum and manifesta-tions of diseases in chil-dren are aff ected and

modifi ed by their age and developmental status, and con-versely various diseases can adversely aff ect the growth and development of children. There is an increasing evi-dence to suggest that seeds of most adult diseases such as obesity, metabolic syndrome X, type 2 diabetes mellitus, stroke, and osteoporosis are sown during childhood. Pedi-atrics deals with the promotion of health and well-being of children and not merely diagnosis and treatment of dis-eases of children. Pediatricians should, therefore, provide health promoting, preventive, curative, and rehabilitative services to children from birth through adolescence. Chil-dren truly constitute the foundation of a nation because healthy children grow to become healthy and strong adults who can actively participate in the developmental activities of a nation.

Diff erences between the Health Care of Children and Adults

1. Children are dependent on their parents or caretak-ers and health care professionals for their nutritional and health needs. Educated, well-informed, econom-ically independent, and adjusted parents can provide better health care to their children.

Health care of children is the most cost-eff ective strategy—saving the life of a child pro-vides at least 50 years of lease of productive life! And child survival is indeed the key for the success of family welfare and population control pro-gram.

2. Children cannot explain or express their discomfort and therefore identifi cation and diagnosis of dis-eases may be delayed if parents are not intelligent, observant, and concerned. Pediatricians need greater clinical acumen and skills to diagnose diseases in chil-dren because they depend on the secondhand infor-mation or history provided by parents or caretakers.

3. Childhood period is characterized by rapid physical growth and mental development. Depending on the developmental status, diseases behave diff erently at diff erent age groups. Diseases produce non-specifi c symptoms and signs and take a more serious course in newborns and infants.

4. Diseases in children may adversely aff ect their physi-cal growth and mental development. Children with recurrent or chronic diseases are prone to develop nutritional problems and stunted growth.

5. Because of their wide range of body sizes (ranging in body weight from 1 kg at birth to more than 50 kg at adolescence) and developmental status at diff erent ages, the children need medical equipment of diff er-ent sizes and sophistication.

6. Nutritional and caloric needs of children per unit body weight are higher because they need extra energy for rapid physical growth and high level of physical activity. Nutritional disorders are more common in children compared with adults. Their needs for fl uids, electrolytes, calories, and nutrients are calculated on the basis of their age and body weight.

7. Children are at increased risk for developing a variety of infectious diseases during their fi rst or nascent con-tact with microbes because they lack any protective antibodies. Adults in general are less likely to suff er from common infectious diseases because they have developed protective antibodies by virtue of previous infections or immunizations during childhood.

8. Children are not mini-adults because they have ana-tomical and functional immaturity of various body organs at diff erent stages of life. They are prone to rapidly develop life-threatening medical emergencies because of their physiological instability. Children are like fl owers—they can rapidly wither following an acute illness but are endowed with tremendous recuperative capabilities; and when tended with care, compassion, and due concern for their physio-logical handicaps, they bloom back to life with equal ease.

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A Manual of Essential Pediatrics2

� Infants Children aged between birth and up to their fi rst birthday are called infants. They should be provided exclusive breastfeeding (even water should not be given) up to fi rst 6 months of life and contin-ued for at least 1 year and preferably longer. � Toddler or preschool child Children aged between 1 and 3 years are called toddlers or preschool chil-dren. They are most vulnerable to nutritional disor-ders and growth faltering because they are started on complementary or weaning foods and are ex-posed to a variety of infections with increased risk of diarrheal disorders. Adequate nutrition or optimal nutrition during 0 to 3 years of age is most crucial for optimal physical growth and brain development. It is believed that linear growth or height achieved at the age of 3 years is a good predictor of ultimate adult height or stature. � Under-5 children Children between the age of 0 and 5 years are called under-5 children. They are particu-larly vulnerable to a variety of vaccine-preventable diseases, diarrheal disorders, and respiratory infec-tions. � School-going children Children aged between 3 and 5 years are often sent to play schools or kindergar-tens and they join regular schools after 5 years of age. When children are fi rst admitted to crèches or play schools, they often suff er from frequent gastrointesti-nal or respiratory infections because of close contact with a large number of children. After entry to a regu-lar school, the risk of intercurrent infections among healthy children becomes less. � Adolescents Adolescence is a phase of childhood, which is characterized by rapid physical growth, sexual maturation, and emotional development. The physical changes and sexual maturation during ado-lescence are triggered by hormonal changes. Girls mature both sexually and emotionally earlier than boys by 2 years. In girls, pubertal changes take place between the age of 10 and 16 years. A large majority of girls begin their sexual development at the age of 10 years and have their fi rst menstrual period around

9. The drug dosages in children are calculated on the basis of their age, body weight, or surface area. In view of small doses in infants, the safety margin of drugs is small and hence extra caution and care should be taken while administering drugs to children.

10. Vital signs vary in children depending on their age. Body temperature is maintained within the narrow range of 98.2°F ± 0.7°F (36.8°C ± 0.4°C) at all ages. However, temperature is more labile and unstable in newborns and infants. Vital signs at diff erent age groups are shown in Table 1.1.

11. Congenital malformations and developmental disor-ders including genetic and chromosomal disorders, are mostly seen during childhood. Cancer and ma-lignant disorders do occur in children, but they are more common among adults. Atherosclerosis, coro-nary artery disease, and adult-onset diabetes melli-tus occur in adults, but the seeds of these diseases are often sown in early life because of poor fetal growth (intrauterine growth retardation) and overnutrition or unhealthy lifestyle during childhood.

1.2 Age Groups in Children

Pediatricians look after children from birth up to 12 years of age. Until now adolescents or children between 12 and 18 years of age were not looked after either by internists (physicians for adults) or by pediatricians. In most devel-oped countries in the west, adolescents are being looked after by pediatricians and there are separate male and female wards for adolescents. In India, many pediatricians provide ambulatory or outpatient department (OPD) care to adolescent children, but hospitals do not have separate wards for adolescents. � Newborns Children aged between birth and up to 28 days of life are called newborns or neonates. They are delicate and have distinctive health problems, with high morbidity and mortality demanding spe-cialized health care facilities.

Table 1.1 Vital signs at diff erent ages

Vital signs Newborns (term baby) Infants (up to 1 y) 2–5 y Above 5 y

Temperature (oral °F) 98.2 ± 0.7 98.2 ± 0.7 98.2 ± 0.7 98.2 ± 0.7

Heart rate (beats/min) 140a 120 100 80

Respiratory rate (rate/min) 40a 30 20 18

Blood pressure (mm Hg) 60/40b 70/50 90/50 110/80

Abbreviation: y, year(s).

aHeart rate and respiratory rate in a newborn are double that of an adult.bBlood pressure in a newborn is one-half that of an adult.


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1 Introduction to Pediatrics 3

when compared with children belonging to other Asian countries of the region (Table 1.2). Undernourished chil-dren are prone to develop frequent day-to-day infections and directly or indirectly account for more than 50% of all deaths in childhood. Because of progressive elimination of dietary defi ciencies of calories and proteins, defi ciencies of micronutrients have assumed public health relevance. Recent studies conducted at the National Institute of Nutrition, Hyderabad, India, have shown that more than 50% of apparently healthy school-going children from middle-income families have subclinical or biochemical defi ciencies of micronutrients.

The provision of optimal nutrition is of fundamen-tal importance to improve child health and survival. The nutrition-sensitive age groups that should be accorded special attention include fetal period (70% brain growth), preschool children or first 3 years of life (determinant of ultimate adult height), and adolescence or phase of sexual maturation (contribute 20% of ulti-mate stature and 50% of adult bone mass). It is impor-tant to remember that nutrition during early life (fetal and infancy) is entirely transmaternal. It is, therefore, necessary to ensure adequate nutrition throughout the “life cycle” of girls along with provision of nutritional supplements to the mother during pregnancy and lac-tation to enhance fetal growth and improve the quality of breast milk. Promotion of exclusive breastfeeding for first 6 months, weaning with home-based nutritious foods, prevention of day-to-day infections by ensur-ing adequate environmental sanitation and personal hygiene, and timely administration of various vaccines are mandatory to improve nutrition of children and enhance their survival.

12 years of age. An average boy starts puberty around 12 years and achieves sexual maturity during 14 to 18 years. When full sexual maturation is achieved, the epiphyses of the long bones fuse with their diaphyses and there is no further linear growth or increase in height. After completion of puberty, a girl becomes a woman and a boy becomes a man.

1.3 Maternal Health and Child Survival

Health and well-being of children is intimately linked with health, nutrition, education, and awareness of their moth-ers. Mothers are the creators and sustainers of human progeny. Health and well-being of a baby in the womb depends on the health and nutrition of his/her mother (not the father!) because mother is the sole provider of food and nutrition to the fetus for 9 months. Healthy moth-ers produce healthy babies and are in a better position to look after the health and well-being of their children. It is important, therefore, to provide a life cycle approach for the care of girl children with a focus on equal opportuni-ties for their nutrition (from birth through infancy, child-hood, adolescence, pregnancy, and lactation), health care, education, dignity, empowerment, and status to have a say in the society.

1.4 Interaction between Nature and Nurture

The growth and development (including intelligence, emotional, social, courage, confi dence, and enthusiasm quotients) of children depend on the interaction between their genetic potential that is racial and ethnic background, constitution, and genome and environmental conditions, and availability of adequate nutrition, safe drinking water and lack of pollution, physical and fun activities, and love and emotional support from parents, family members, friends, and teachers. Among various environmental fac-tors, adequate nutrition is most critical for optimal growth and well-being of children.

1.5 Importance of Nutrition

Undernutrition is the core health problem in children. Children are vulnerable to develop nutritional disor-ders because they are dependent on their parents and caretakers to meet their nutritional requirements. Their caloric and protein requirements are higher to sustain their rapid growth velocity and meet the nutritional demands of physical activity and intercurrent infec-tions to which they are highly vulnerable. In India, 28% of babies are of low birth weight (<2.5 kg) and approxi-mately 48% of under-5 children have stunted growth. The nutritional status of under-5 children in India is dismal

Table 1.2 Salient nutritional indicators of under-5 children in Asian region

Country Low birth weight

babies (%)Underweight children (%)

Stunted children (%)

India 28 43 48

Bangladesh 22 41 43

Pakistan 32 31 42

Myanmar 9 23 35

Indonesia 9 18 37

Thailand 7 7 16

China 3 4 10

Source: The State of the World’s Children, UNICEF 2012.

Note: Low birth weight babies, birth weight of less than 2.5 kg irrespective of the period of gestation; underweight children, weight less than 22 SD of median weight-for-age of NCHS/WHO reference standard; stunted children, height less than 22 SD of median height-for-age of NCHS/WHO reference standard.


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During clinical as-sessment, be relaxed and focused and visualize every patient as a puz-zle and enjoy in trying to solve it. Pediatricians need all the skills of a detective, lawyer, and a judge to understand

and diagnose the disease process. They should be thorough in taking a detailed history and doing a complete physical examination. According to Henry Cohen, “most errors in clinical evaluation are made by doing a cursory and hurried examination and not due to lack of knowledge and skills.”

1.8 Management Strategies

There are several guidelines and principles to provide rational therapy. Eff orts should be made to practice evi-dence-based pediatrics, which should be complemented by personal experience, expertise, and common sense to promote best child-care practices. Symptomatic and spe-cifi c therapy should be instituted after making a tentative diagnosis and a “shotgun” therapy is condemned. Every patient with fever should not be treated with antibiotics or antimalarials unless they are indicated.

Every child is unique and no two children are alike. There are diff er-ences in the constitution, genetic stock, nutritional status, immunologic integrity, eco logy, envi-

ronment, and so on. It is important to remember that not only the same medicine from diff erent doctors has diff erent eff ects but also the same medicine from the same doctor is likely to have diff erent eff ects on diff erent patients. An identical disease such as “cough and cold” can behave dif-ferently in diff erent patients. Rapid strides have been made in the fi eld of pharmacogenomics in an attempt to produce tailor-made medicines to suit the genetic constitution of patients.

There are a large number of modalities of therapy pertaining to diff erent systems of medicine to treat various diseases (see

Box). The availability of a large number of options indi-cates that none is foolproof and one should try to exploit various modalities to provide healing—keeping in mind that nature, time, patience, faith, hope, and prayer are great healers. Nevertheless, it is important to remember that availability of safe and eff ective vaccines, antibiot-ics, lifesaving drugs, management of emergencies, and surgical interventions for repair and replacement of body

“The physician should have faith in his clinical acumen and should treat the patient and not his laboratory reports.”

– John Apley

“When a lot of medicines are suggested for a disease that means it cannot be cured.”

– Anton Chekhov

It is a paradox that not only undernutrition but also overnutrition is assuming public health relevance among children belonging to the affl uent segments of our society. Surveys have shown that almost one-fourth of adolescents in public schools are obese. These children are prone to develop metabolic syndrome X, type 2 diabetes mellitus, and cardiovascular diseases early in adult life. Therefore, the key to child survival and ensuring good quality of life is to provide optimal nutrition by preventing both under- as well as overnutrition. It is important that fundamentals of nutrition, mothercraft, and family life education should be taught to teenage boys and girls attending high school so that they grow to become well-informed citizens and responsible parents.

1.6 Doctor–Patient Relationship

Because of various reasons there is a gradual erosion of time-honored sacred relationship between the doctor and patients. When parents have faith and trust in their doctor, it augments the process of healing. Therefore, the parents and patients must have faith and trust in their physician and physicians must have confidence in themselves and the drugs they prescribe. Physicians should strive to handle sick children and their parents with confidence, competence, due concern, and com-passion to establish a bond of trust and faith. On the other hand, hurry, worry, indecision, and lack of self-confidence weaken the doctor–patient bond. Physicians should try to listen more and talk less while taking history and interacting with parents/patients to allow them to give vent to their observations, feelings, and concerns.

1.7 Art of Pediatrics

Children should be han-dled as children (not patients!) and with due care and compassion as well as in a relaxed and playful manner. Physi-cians should always greet the child with a

smile and not scare the child by staring or looking intently into his eyes. Unlike adults, children distrust a person who looks directly into their eyes. “Sneaky” observation is the best mantra to elicit the cooperation of a child. Off er a toy and ignore the child while taking history—the best way to make friends with a child is not to try. Examine children with warm hands and warm heart preferably in the com-fort of lap of their mothers. In case of school-going chil-dren, it is best to get fi rsthand information directly from the child.

“We should not allow the tech-nology to further dehumanize medicine and we must treat children not only with our heads but also with our hearts.”

– Meharban Singh

“There are no short cuts to physical diagnosis. It is learnt by all the fi ve senses alert. Eyes, ears, nose and palpating fi ngers are the gems of a physician – in-tact brain is the necklace.”

– Hippocrates


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To avoid therapeutic misadventures, there are fi ve mes-sages or pearls of wisdom encapsulated in the above quote:

1. Many diseases are self-limiting and they recover spontaneously without any drugs. Nature, time, and patience are the three great physicians.

2. We should not be enamored and fascinated or carried away to use newer drugs that have not withstood the test of time and we should remember the well-known dictum that “old is gold.”

3. Art of medicine should not be sacrifi ced at the altar of technology.

4. Patients should not be viewed as systems or organs but in their totality—body, mind, soul, and society. We should provide holistic “care” and not mere “cure.”

5. Medicines should not cause more harm to the patient than the disease itself for which they are prescribed. We must use those medicines that have withstood the test of time with an assured effi cacy and safety track record.

1.10 Ethical Concerns

There is increasing commercialization and gradual decline of human values at all levels of our society and doctors are no exception. The Box summarizes various correlates and types of malpractices that are prevalent in our country.

Common correlates and types of unethical practices

� Change of social values and everyone wants to become “rich overnight.”

� Doctors are competing with each other to create rev-enue for the corporate hospital by fair or foul means.

� Exorbitant cost of medical education in the private sector.

� Unnecessary diagnostic studies to get “cuts” or the laboratory is owned by the physician.

� “Kickbacks” for referrals.

� Needless hospital admissions.

� Superfl uous medical procedures such as endoscopies and biopsies.

� Unnecessary surgical procedures or even surgical operations.

� Self-promotion through advertisements.

It is important that medicine should be practiced with a conscience, dignity, and professionalism and without any ulterior or sole motive of making money. Mother Teresa extolled that “medicine should not be considered merely another profession but a mission in life.” Physicians should never criticize or say a slighting word against their

organs are the greatest assets of the modern system of medicine.

Therapeutic modalities and interventions to promote healing

� Drugs such as allopathic, homeopathic, ayurvedic, siddha, and unani

� Surgery: corrective repair and replacement

� Psychotherapy

� Physiotherapy

� Acupuncture and acupressure

� Hypnotherapy

� Magnetic therapy

� Yoga

� Music therapy

� Aroma therapy

� Gemology

� Naturopathy

� Visualization

� Reiki

� Meditation

� Art of living

� Prayer

1.9 Holistic Care

Patients should not be viewed as systems, organs, tissues, cells, and DNA. They must be viewed in totality—body, mind, heart, and soul, and that too not in isolation but in context with the dynamics of ecology, family, friends, and society. We should treat the child and not his or her disease or investigation reports. Every contact with the family should be harnessed to provide “holistic care” and not mere “cure.” We must give advice regarding lifestyle changes, importance of personal hygiene, benefi ts of breastfeeding, importance of safe drinking water, environmental sanitation, optimal nutrition, immunizations, and prevention of accidents.

The principles of rational management of diseases and provision of holistic care have been beautifully summed up by Sir Robert Hutchison in the following quotation:

“From inability to let well alone, from too much zeal for the new and contempt for what is old, from putting knowledge before wisdom, science before art and cleverness before commonsense, treating patients as cases, from making the cure of the disease more grievous than endurance of the same, good Lord deliver us.”


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combination of continuous registration and half-yearly surveys. There are wide variations in indices of health in diff erent states of the country and between affl uent seg-ments and underprivileged urban and rural communi-ties. The current population of India is estimated to be approximately 1,224,614,000 (more than 1.2 billion). The country is overcrowded and thickly populated because it accounts for 2.4% of the global land area where 17.5% of the world’s population lives (Table 1.3). There has been

colleagues. It is important that doctors remain transpar-ent in their dealings and avoid unnecessary investigations, procedures, and hospital admissions. There is an urgent need that medical students, both graduate and postgradu-ates, be taught the subjects of humanities, social sciences, communication skills, and medical ethics.

1.11 Art of Communication

Most parental complaints of mismanagement originate because of lack of communication or because of abrasive or callous attitude of the doctor or health care professional rather than because of lack of skills or faulty technical management of the patient. Humility, concern, empathy, and compassion are crucial to generate faith and provide emotional support to the family. Be relaxed, patient, and polite during interaction with the patient’s family and always consider patient as a client. Even if the enquiry or query of the parents is illogical, repetitive, and irritating, physicians must respond with due grace, equanimity, and calmness without any hurry, anger, or arrogance.

The physician must establish a rapport with the child and his/her parents to provide them emotional support and win their faith, trust, and confi dence. The pediatrician who exhib-its evidences of worry, hurry, and indecision is unlikely to inspire any confi dence in their patients or attendants.

What physicians do not say and what they say, how and when they say, make all the diff erence between helping and not helping the patients. A skillful physician knows when to sedate with drugs, when to console with words, and when to treat aggressively for cure or palliatively to provide symp-tomatic relief. The patients and attendants have emotional feelings and one should avoid saying that “nothing can be done” (because something can always be done), “there is nothing wrong”—even when it is a functional disorder. For a critically unwell child, always give a guarded prognosis that can by tempered with hope and godly benevolence.

1.12 Salient Vital Statistics

Vital statistics refer to systematically collected demo-graphic data pertaining to vital health parameters. In India, the main sources of vital statistics include the census; registration records of vital events such as births, deaths, and sample registration system; and the National Family Health Survey (NFHS). Sample registration system obtains annual information on birth and death rates, fertility rates, and age-specifi c mortality rates in the country through a

“A person may have learnt a great deal and still be an ex-ceedingly unskillful physician who awakens little confi dence in his patients. . . . The manner of dealing with patients, the manner of winning their confi -dence and the art of soothing and consoling them. . . . All this cannot be learnt from books.”

– John Apley

Table 1.3 Salient demographic, maternal, and child health indicators

Indicators Values � Basic indicators

� Annual births 27,165,000

� Neonatal mortality rate 32

� Infant mortality rate 48

� Under-5 mortality rate 63

� Life expectancy at birth

� Male 66 y

� Female 68 y

� Adult literacy rate

� Male 88%

� Female 74%

� Nutritional status

� Low birth weight babies 28%

� Under-5 children

� Underweight 43%

� Wasted 20%

� Stunted 48%

� Maternal indicators

� Antenatal coverage

� At least once 75%

� At least four times 51%

� Skilled attendant at delivery 53%

� Urban 76%

� Rural 47%

� Institutional deliveries 47%

� Maternal mortality rate(per 100,000 live births)

250

� Total fertility rate 2.6

� Annual population growth rate 2.5

Abbreviation: y, year(s).

Source: The State of the World’s Children, UNICEF 2012.

Note: Underweight, below 22 SD from median weight-for-age; wasted below 22 SD from median weight-for-height; stunted below 22 SD from median height-for-age.


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5. Ensure availability of good quality antenatal care facilities and safe delivery (either at a health post or by a trained birth attendant) in 100% of cases.

6. Ensure availability of essential newborn care facili-ties and promote exclusive breastfeeding, universal immunizations, and early detection and manage-ment of common childhood illnesses such as diar-rhea and respiratory infections by promoting oral rehydration solution and rational use of antibiotics.

7. Health and social activities should be reinforced and integrated by active involvement of non- governmental organizations to improve the socio-economic status and quality of life at the individual family level.

8. The World Health Organization and the United Nations Children’s Fund have launched integrated management of neonatal and childhood illnesses modules by providing hands-on clinical skills to health workers to manage common health problems in children with the help of algorithms. Apart from rational management of common diseases, health workers promote breastfeeding and provide immu-nizations as well as health and nutrition education. The emphasis has shifted from purely curative ser-vices to a package of comprehensive health promo-tive and preventive services at each contact of the health worker with the families. Under the National Rural Health Mission, it has been proposed to create a new cadre of community-based female health func-tionaries, named as accredited social health activists (ASHAs), to provide essential health care services at the doorstep of people.

1.14 Hospital Care of Sick Children

Children wards and hospitals for ill children should have their distinct identity along with necessary facilities and features to make them child-friendly. There should be small cots with railings as well as standard adult beds for older children. Each bed should be provided with a cen-tralized source of oxygen and suction. Because of shortage of nurses and to avoid separation anxiety and fear of stran-gers and strange environment, the mother or a lady atten-dant should be allowed to stay with the child round the clock. A comfortable padded bench and a locker should be provided next to the bed for the comfort of the mother or attendant. Two bays adjacent to the nursing station should be provided to admit moderately sick children requiring intravenous fl uid therapy and close monitoring by the nurses. These patients should be visible to the nurses from the nursing station through the glass walls.

The walls of the ward should be decorated with colorful and innovative designs of indigenous cartoon characters. A procedure room should be available in each unit. Each pediatric unit should be provided with three to four inde-pendent rooms with an attached bathroom for isolation

gradual improvement in the health statistics and health indices in the country, but they are far from being satisfac-tory. The National Population Policy 2000 has laid down the health objectives and national sociodemographic goals to be achieved (see Box).

National population policy goals to be achieved by India

� Provide the essential unmet needs for basic reproductive and child health infrastructure, services, and supplies.

� Ensure free and compulsory school education up to 14 years of age.

� Achieve 100% deliveries by trained health personnel.

� Achieve 100% immunization coverage.

� Achieve 100% registration of pregnancies, births, and deaths.

� Reduce infant mortality rate to below 30 per 1000 live births.

� Reduce maternal mortality rate to below 100 per 100,000 live births.

� Promote small family norm.

� Achieve universal access to safe drinking water, health care, information, and counseling.

1.13 Strategies for Child Survival

The four pillars of good health are sound genetic consti-tution, safe environment, wholesome food, and healthy lifestyle. The National Population Policy and the National Rural Health Mission have outlined several strategies to improve child survival and reduce avoidable human wast-age by implementing the following strategies:

1. Health and well-being of children is intimately linked to the health, education, and nutrition of their moth-ers. Healthy and well-informed mothers produce healthy children and are in a better position to take proper care of their children.

2. Girl children should be accorded essential health care, nutrition, and formal education without any discrimination. Ensure 100% literacy rate and provide adequate nutrition throughout the life cycle of girls—infancy, childhood, adolescence, pregnancy, and lac-tation. Women are the creators and sustainers of the progeny and they should be fi nancially independent and empowered to have a say in the society.

3. Ensure availability of safe drinking water and satis-factory environmental sanitation and provide health and nutrition education to the community on a pri-ority basis.

4. Provide adequate infrastructure and operationalize credible facilities for essential family welfare, repro-ductive, and child health services within easy reach.


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by children while playing does not disturb other children who are ill. A dining room is an essential requirement because children do eat better in the company of other children. Children are fussy in their food habits and their fussiness becomes worse when they are unwell. Dining room with a television set and other ancillary facilities does encourage and motivate ill children to eat better. The washrooms and toilet facilities should cater to the needs of children as well as their mothers and attendants. Chil-dren should be provided with a colorful and clean dress from the hospital and their dress should be changed daily. Bed linen and sheets must also be changed daily because children are more likely to soil them. The colorful dress of the nurses and avoidance of white coat by the doctors are likely to enhance nurse–child and doctor–child relation-ship and cooperation.

of children who are immunocompromised or suff ering from contagious diseases. They should be provided with gowning and hand washing facilities. In each pediatric unit, provision must also be made for a pantry and formula room to dispense special diets. A well-equipped pediatric intensive care unit (PICU) with all the essential monitoring and therapeutic electronic equipment should be provided to look after critically ill children with life-threatening medical disorders. On an average 20% of beds should be earmarked for pediatric emergencies—a 100-bedded chil-dren ward should have a 20-bedded PICU.

Children should be provided home-friendly ambience in the hospital. Eff orts should be made to keep them busy and in good mood. A playroom with necessary toys and indoor games should be available. Playroom should be located in the corner of the ward so that the noise made

Further Reading

Behrman RE. Overview of pediatrics. In: Kliegman RM, Behr-man RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pedi-atrics. 18th ed. New Delhi, India: Elsevier; 2007:1–12.Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002;325(7366):697–700. Parsons TJ, Power C, Logan S, Summerbell CD. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord 1999;23(Suppl 8):S1–S107. Saunders J. The practice of clinical medicine as an art and as a science. Med Humanit 2000;26(1):18–22. Singh M. The Art and Science of Baby and Child Care. 3rd ed. New Delhi, India: Sagar Publications; 2007.

Singh M. The art of pediatric diagnosis. In: Pediatric Clini-cal Methods. 4th ed. New Delhi, India: Sagar Publications; 2011:1–11.Singh M. Ethical considerations in pediatric intensive care unit: Indian perspective. Indian Pediatr 1996;33(4): 271–278. Singh M. The art, science and philosophy of child care. Indian J Pediatr 2009;76(2):171–176. United Nations Children’s Fund. The State of the World’s Children. New York, NY: UNICEF; 2012.

Commonly Asked Questions

Why pediatrics is equated to veterinary medicine?

In a lighter vein, pediatrics is equated to veterinary medi-cine because young children cannot explain the symptoms of their disease. When in discomfort, they merely cry but are unable to explain the site or the nature of discomfort or pain. However, an intelligent and observant mother (at times even the father!) can explain the nature of symptoms and sequence of events. Nevertheless, pediatricians do need greater clinical acumen and skills to diagnose the nature of disease in children. Most school-going children can give an accurate account of their illness and they must be directly asked to explain the nature and sequence of their symptoms.

Why are children more prone to develop nutritional problems?

Undernutrition is the core health problem in children. Children are dependent on their parents and health care professionals for their nutritional and health needs. Unlike other mammals, human babies take much longer to become independent. They need extra calories and additional micronutrients to sustain their rapid physical

growth and high activity level. They are prone to suff er from recurrent day-to-day infections including acute diarrhea that further compromises their nutritional sta-tus. Children have strong likes and dislikes and they are fussy or fi nicky in their food habits. The average caloric needs of infants are around 120 kcal/kg, which is at least three times that of an adult (40 kcal/kg).

What diseases are more common in children compared with adults?

Children are more likely to have diseases and disorders because of structural and functional immaturity of various body organs, infections, infestations, nutritional disorders, congenital malformations, developmental disorders, and also inborn errors of metabolism because of genetic disorders.

What do you understand by transmaternal nutrition?

During fetal life and infancy, which is the most crucial and rapid phase of child development, nutrition is provided to the baby entirely through maternal sources. During


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of Parents.” Such organizations bring together families of children having similar medical problems and help form a network and learn from each other by sharing mutual con-cerns and diffi culties and by eff ective utilization of avail-able specialized services.

How to handle a family when its child dies in the hospital?

Despite all the techno-logical advances, medi-cine can never achieve immortality. It is as natural to die as to be born. During physicians’ career, they are likely to face several “end-

of-life situations” and deaths despite of their best eff orts. The coping of death of a child in the hospital is a painful and challenging experience for everybody concerned with the care of the child. Death defl ates our ego and teaches us humility and provides strength to face and accept the greatest reality and truth of life that we should handle with equanimity, composure, and confi dence. During the care of critically sick children in intensive care unit, it is important to show due concern, care, and compassion to the parents and keep them duly informed about the condition and care of their child. It is important that physicians not only pro-vide state-of-the-art care to the child but also make the parents and attendants perceive that what was humanely possible was done for the care of their baby. The desire of parents that death should occur in the familiar atmosphere of home rather than a hospital should be honored. A fam-ily’s wish for religious support (such as amulets, mantras, and holy water) and the presence of a priest at bedside should be allowed. The family should be emotionally and spiritually prepared before declaration of death. The news of death should be conveyed with utmost compassion but in no unmistakable terms that the child has died despite of best intents and eff orts. When a child is conscious and dying, the parents should be at his bedside holding his hand and talking with him to allay his fears and assist him to express his concerns, desires, and emotions.

“Death is certain for the born, and rebirth is inevitable for the dead. You should not, there-fore, grieve over the inevita-ble.”

– The Bhagvad Gita

pregnancy, nutrition and well-being of the mother deter-mine the adequacy of fetal growth, health, and well-being of the fetus. After birth, exclusive breastfeeding is recom-mended for the fi rst 6 months of life. The adequacy and qual-ity of breast milk is determined by the health and nutritional status of the mother. Therefore, during fetal life and the fi rst 6 months of infancy, nutritional status and well-being of the baby is entirely dependent on the nutritional status and nutritional supplements taken by the mother during preg-nancy and lactation. To provide a strong foundation and good start to life, it is crucial to provide a life cycle approach to health care and nutrition of girl children from infancy through adolescence, pregnancy, and lactation. Women indeed are the creators and sustainers of human progeny.

How to communicate bad news to a family?

When a child is suff ering from a chronic or incurable dis-ease or an affl iction with lifelong disability, the parents are likely to respond with disbelief, anger, shock, or feeling of hopelessness. The news should preferably be given to both the parents simultaneously in a relaxed sitting with due concern, compassion, and empathy. The facts should be explained in a simple language without any medical jargons. The nature of disease, likely prognosis, available therapeutic interventions, the cost of care, etc., should be explained. Physicians should allow the parents to ventilate their feelings and concerns and try to answer their queries in an honest and unambiguous manner. They should try to follow the well-known philosophy, “talk less and listen more,” that is why God has given us one mouth and two ears. Physicians should be pragmatic but not pessimistic and remain hopeful, which is a great healing force, and also remember that miracles do happen. We should be careful and diplomatic in conveying the nature of disease without hurting parental feelings. Instead of bluntly say-ing that “your child is mentally retarded,” it is preferable to use words wisely, for example, the child is rather “slow” or having “developmental delay.” In Indian society, giving spiritual advice to parents of such children is common. For example, an advice such as, “God has chosen you to provide care and comfort to this special child because you are so compassionate, caring and sensitive human being” may encourage the family to join “Self Help Associations


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Health & Medicine

A Manual of Essential Pediatrics-Meharban Singh