PREVENTIVE PAEDIATRICS

I INTRODUCTION

Child health depends upon preventive care. Majority of child health problems
are preventable. Preventive pediatrics is a specialized area of child health
comprises efforts to avert rather than cure disease and disabilities. Preventive
pediatrics been broadly divided into antenatal preventive pediatrics and
postnatal preventive pediatrics. Antenatal preventive pediatrics includes care of
the pregnant mothers with adequate nutrition, prevention of communicable
diseases, preparation of the mother for delivery, breastfeeding and mothercraft
training, etc, pre pregnant health status of the mother also influences the child
health. Promotion of health of girl child and nonpregnant state should be
emphasized as the future mother, who is soil and seed of future generation.
Postnatal preventive pediatrics includes promotion of breastfeeding,
introduction of complementary feeding in appropriate age, immunization,
prevention of accidents, tender loving care with emotional security, growth
monitoring, periodic medical supervision and health check-up, psychological
assessment, etc.
II DEFINITION
1. PEDIATRICS
Pediatrics can be defined as the branch of medical science that deals with the
care of children, from conception to adolescence, in health and illness. It is
concerned with preventive, curative, and rehabilitative care of children.
- SUDHAKAR

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2. PEDIATRIC NURSING
Pediatric nursing is defined as the specialized area of the nursing practice
concerning the care of children during wellness and illness, which includes
preventive, promotive, curative and rehabilitative care of children.
- A.SUDHAKAR
3. PREVENTIVE PEDIATRICS
Preventive pediatrics has been defined as “the prevention of disease and
promotion of physical, mental and social wellbeing of children with the aim of
attaining a positive health”.
- PARUL DUTTA
III. CONCEPT OF PREVENTIVE PEDIATRICS
Pediatrics which is synonymous with child health is that branch of medical
science that deals with the care of children from conception to adolescence, in
health and disease. Pediatrics is one of the first clinical subjects to link itself to
preventive medicine. Like obstetrics, pediatrics has a large component of
preventive and social medicine. There is no other discipline so comprehensive
as pediatrics that teaches the value of preventive medicine. Recent years have
witnessed further specialization within the broad field of pediatrics viz.
preventive pediatrics, social pediatrics, pediatric surgery, pediatric neurology,
and so on.
Preventive pediatrics comprises efforts to avert rather than cure disease and
disabilities. It has been broadly divided into antenatal pediatrics and postnatal
pediatrics. The aims of preventive pediatrics and preventive medicine are the
same: prevention of disease and promotion of physical, mental and social well-
being of children so that each child may achieve the genetic potential with
which he/she is born. To achieve these aims, hospitals for children have adopted
the strategy of “primary health care to improve child health care through such
activities as growth monitoring, oral rehydration, nutritional surveillance,
promotion of breast feeding, immunization, community feeding, regular health

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check-ups, etc. Primary health care with its potential for vastly increased
coverage through an integrated system of service delivery is increasingly looked
upon as the best solution to reach millions of children, especially those who are
most in need of preventive and curative services.
Another new concept of child health care is social pediatrics. The challenge of
the time is to study child health in relation to community to social values and to
social policy. Social pediatrics has been defined as “The application of the
principles of social medicine to pediatrics to obtain a more complete
understanding of the problems of children in order to prevent and treat disease
and promote their adequate growth and development, through an organized
health structure. It is concerned with the delivery of comprehensive and
continuous child health care services and to bring these services within the
reach of the total community. It also covers the various social welfare measures-
local, national and international-aimed to meet the health needs of a child. For
the comprehensive services to the mothers and children, primary health care
strategy is adopted by the health care delivery system. Government of India
accepted a national policy for children in 1974 and implemented various health
programs for preventive and social services along with curative care for the
millions of children.
Includes.
 Family health
 Maternal & Child Health (MCH)
 Reproductive & Child Health (RCH)
 Breast feeding
 Baby Friendly Hospital Initiative (BFHI)
 Weaning
 Integrated Child Development Scheme (ICDS)
 Under five clinic
 Immunization
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 School Health Service

 FAMILY HEALTH
Family health means the overall health of the individual family members. It is
influenced by the interrelationship and interdependence of the physical and
mental health status of the individual members of the family.
Child health depends upon the family’s physical, social, economical and
environmental conditions, which include family size, family income, standard
of living, parents, education, culture, customs, traditional habits, child bearing
and child rearing practices, family relationship, family stability etc,.
Factors of family health services:
Reduction of maternal, infant and child mortality and morbidity rates.
Improvement of family planning practices and to ensure Planned Parenthood.
Improvement of nutritional status all family members. Increasing health
awareness through health education in all preventive, curative and rehabilitative
aspects of health care.
Sub-areas of family health
 Maternal and child health service including immunization.
 Family welfare services.
 Nutritional services.
 Health education.
Factors influencing family health:
 Environmental factors-housing, sanitation, drinking water supply,
pollution etc.
 Economical factors-Income and expenditure in the family.
 Educational factors-Parents education especially mother’s education and
level of literacy of other family members.
 Social factors-Culture, customs, food habits, health habit, family size,
fertility rate etc
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 MATERNAL AND CHILD HEALTH (MCH)

Maternal and child health refers to the promotive, preventive, curative and
rehabilitative health care for mothers and children.
The components of maternal and child health include the sub-areas of maternal
health, child health, family planning, school health, handicapped children,
adolescence and health aspects of care of children in special care setting e.g. day
care centres.
Specific objectives of MCH care are:
 Reduction of maternal, perinatal, infant, and child mortality and
mortality.
 Promotion of reproductive health, e.g. postponing unwanted arrival of
child, adequate spacing between two children and containment of population
explosion.
 Promotion of physical and psychological development of the child and
adolescent within the family:
The important health problems affecting the mother and child are mainly
malnutrition, infections, and hazards associated with uncontrolled reproduction
or fertility. MCH services in India are now delivered as a ‘package’ services
against these problems to promote continuity of care and to reduce number of
visits by mother for herself and for the child.
The MCH care package services include antenatal care, intranatal care, and
perinatal care, postnatal care, and nutrition advice immunization, primary health
care and rational family planning.

MCH services highlight the concept of mother and child as one unit because the
child health is closely related to maternal health and a healthy mother only can
bring a healthy child.

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  REPRODUCTIVE AND CHILD HEALTH (RCH)

“Reproductive and child health approach has been defined as people have the
ability to reproduce and regulate their fertility, women are go through
pregnancy and child birth safely, the outcome of pregnancies is successful in
terms of maternal and infant survival and wellbeing, and couples are able to
have sexual relations, free of fear of pregnancy and contracting disease”.

Life cycle approach

Safe
child survival
motherhood
Community
Child centered
participation
approach
Family
Adolescent
welfare and
health
planning

Prevention
of RTI/STD

Fig no. 1 Components of RCH program

The RCH services are planned and implemented on the basis of the needs of the
community with client-centered approach. Other management strategies of this
services are target-free, demand-driven, decentralized, participatory, bottom-up
planning with life cycle approach. This program is implemented in the
community level, subcenter level, primary health center level and PRU/ district

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hospital level. The RCH program is not just a new package of services. The
program lays emphasis on quality of services and satisfaction of the consumers.
RCH package

Family Planning Child survival & safe motherhood

component
Client approach to health care Prevention/management of
RTI/STD/AIDS

Table no: 1 RCH Package

Main highlights
 The program integrates all intervention of fertility regulation, maternal
and child health with reproductive health for both men and women
 The services to be provided are client oriented, demand driven high
quality and based on the need of community through decentralized participatory
planning and target free approach.
 The program envisages up gradation of level of facility for providing
various interventions and quality of care.
 The program envisages up gradation of level of facility for providing
various interventions and quality of care.
 Facilities of obstetric care, MTP and IUD insertion in the PHCs level are
improved.
 Specialist facilities for STD and RTI are available in all district hospitals
and a fair number of sub-district hospitals.
 The program aims at improving the outreach of services especially for the
vulnerable groups.

RCH phase 1 launched in 15th October 1997, interventions include:

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 Child survival interventions (immunization, oral rehydration therapy)
 Safe motherhood interventions (antenatal check up, immunization for TT)
 Implementation of target free approach
 High quality training at all levels
 IEC activities
 Specially designed RCH package for urban slums and tribal areas
 District sub-projects under local capacity enhancement
 RTI/STD clinics at district hospitals
 Facility for safe abortions at PHCs by providing equipments& doctors
 Enhanced community participation through panchayath, women’s and
NGOs
 Adolescent health and reproductive hygiene.
OBJECTIVES OF RCH PROGRAM ARE
1. Essential obstetric care
Essential obstetric care intends to provide the basic maternity services to all
pregnant women through early registration of pregnancy (within 12-16 wks),
provision of minimum the antenatal check ups by ANM or medical officer to
monitor progress of pregnancy and to affect any complication so that
appropriate care including referral could be taken in time provision of safe
delivery at home or in an institution, provision of three postnatal check ups.
2. Emergency obstetric care
It is an important intervention to prevent maternal mortality and morbidity.
3. 24 – hour delivery services at PCHs
To promote institutional deliveries, provision has made to give additional
honorarium to the staff to encourage round the clock care services.
4. Medical termination of pregnancy
MTP is a reproductive health measure that enables a women to opt out an
unwanted or unintended pregnancy in certain specified circumstances without
endangering her life, through MTP act 1971.
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Control of reproductive tract infections (RTI) and sexually transmitted diseases
It is implemented in close collaboration with National AIDS Control
Organization. NACO provide assistance for setting up RTI/STD clinics up to
the district level.
5. Immunization
Universal immunization programme (UIP) become a part of CSSM programme
in 1992 and RCH programme in 1997, it will continue to provide vaccines for
polio, tetanus, DPT, measles and tuberculosis.
6. Essential newborn care
Primary goal is to reduce perinatal and neonatal mortality. The main
components are resuscitation of newborn with asphyxia, prevention of
hypothermia, prevention of infection exclusive breast feeding and referral of
sick newborn.
7. Diarrhoeal disease control
India is the first country in the world to introduce the low osmolality oral
rehydration solution, zinc is to be used as an adjunct to ORS for the
management of diarrhea.
8. Acute respiratory disease control
It is an integral part of RCH programme, peripheral health workers are being
trained to recognize and diarrhea. Clotrimoxazole is being supplied to the
health worker.
9. Prevention and control of vitamin A deficiency in children
Under the programme, doses of vitamin A are given to all children under 5
years of age. The first dose (1 lakhs units) is given at nine months of age along
measles vaccine. The second dose (2 lakhs unit) is given after 9 months
subsequent doses (2 lakhs unit) are given at six months intervals up to 5 years of
age. All cases of severe malnutrition to be given one additional dose of vitamin
A.

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10.Iron and control of anaemia in children
To manage anemia, infants from the age of 6 months onwards up to the age of 5
manage to receive iron supplements in liquid formulation in doses of 20 mg
elemental iron 20mcg folic acid per day for 100 days in a year.
On 6-10 years of age will receive iron in the dose of 30mg elemental iron and
250 mcg liquid for 100 days in a year.
Phase II
Phase II began from 1st April, 2005 the focus of the programme is to reduce
maternal and morbidity and mortality with emphasis on rural health care.
Major strategies include
1. Essential obstetric
 Institutional delivery
 Skilled attendance at delivery
2. Emergency obstetric care
 Operationalizing First Referral Units
 Operationalizing PHCs and CHCs for round the clock delivery services.
3. Strengthening referral system.
 BREAST FEEDING

The nature has designed the provision that infants be feed upon their mother’s
milk. They find their food and mother at the same time. It is a complete
nourishment for them both for their body and soul. Breastfeeding is the most
effective way to provide a baby with a caring environment and complete food. It
meets the nutritional well as emotional and psychological needs of the infant.
Breastfeeding is now an endangered practice around the world, in both rich and
poor countries. There is unanimous agreement on the need for, and the route to,
global support for breastfeeding through various approaches and programs.
Baby Friendly Hospital Initiative is one of the important interventions towards
that goal.

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a.Advantages of Breastfeeding

Breastfeeding is safest, cheapest and best protective food for infants. Superiority
of human milk is due to its superior nutritive and protective value. It is perfect
food for infants and provides total nutrient requirements for the first six months
of life. When combined with appropriate weaning foods, it is an invaluable
source of nourishment until past the second birth day. It prevents malnutrition
and allow the child to develop fully.

1. Nutritive Value: Breast milk contains all the nutrients in the right
proportion which are needed for optimum growth and development of the baby
up to 6 months. It is essential for brain growth of the infant because it has high
percentage of lactose and galactose which are important components of
galactocerebroside. It facilitates absorption of calcium which helps in bony
growth. It contains amino acids like taurine and cysteine which important as
neurotransmitters. Breast milk fats are polyunsaturated fatty acids which are
necessary for the myelination of the nervous system. It has vitamins, minerals,
electrolytes and water in the right proportion for the infant which are necessary
for the maturation of the intestinal tract. It provides 66 calories per 100 ml and
contains 1.2 g protein, 3.8 g fat, 7 g lactose and vitamin A 170 to 670 IU,
vitamin ‘C’ 2 to 6 mg, vitamin D 2.2 IU, calcium 35 mg, phosphorus 15 mg in
100 ml, The total amount of milk secretion per day is about 600 to 700 ml,
which is sufficient for the baby. Its composition is ideal for an infant. It
provides specific nutrition for preterm baby in preterm delivery.
2. Digestibility: Breast milk is easily digestable. The protein of breast milk
mostly lactoalbumin and lactoglobulin which form a soft curds that is easy to
digest. The enzyme lipase in the breast milk helps in the digestion of fats and
provides free fatty acids.
3. Protective Value: Breast milk contains IgA, IgM, macrophages,
lymphocytes, bifidus factors, unsaturated lactoferrin, Iysozyme, complement
and interferon. Thus breastfed body less likely to develop infections especially
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gastrointestinal and respiratory tract infections, e.g. diarrhea and ARI. It also
provides protection against malaria and various viral and bacterial infections
like skin infections, septicemia, etc.
4. Psychological Benefits: Breastfeeding promotes close physical and
emotional bondage with the mother by frequent skin to skin contact, attention
and interaction. It stimulates psychomotor and social development. It leads to
better parent child adjustment, fewer behavioral disorders in children and less
risk of child abuse and neglect. Breastfeeding promotes development of higher
intelligence and feeling of security in infant.
5. Maternal Benefits: Breastfeeding reduces the chance of postpartum
hemorrhage and helps in better uterine involution. Lactational amenorrhea
promotes in recovery of iron stores. It can protect from pregnancy for first 6
months if exclusive breastfeeding is carried out. Breastfeeding improves
metabolic efficiency and satisfaction with sense of fulfillment of the mother. It
reduces the risk of breast and ovarian cancer of the mother. It improves
slimming of the mother by consuming extra fat which accumulated during
pregnancy. It is more convenient and time saving for the mother. It is more
convenient and time saving for the mother. Mother can provide fresh, pure,
readymade, clean uncontaminated milk to her baby at right temperature without
any preparations. Mother feels comfortable to feed the baby especially at night.
6. Family and Community Benefits: Breastfeeding is economical in terms
of saving of money, time and energy. Family has to spend less on milk, health
care and illness. Community expenditure on health care and contraception are
reduced. It is economic for the families, hospitals, communities and for
countries.

b.Initiation of Breast feeding

Breastfeeding should be initiated within first half an hour to one hour of birth or
as soon as possible. It should also be initiated within one hour even after
cesarean section delivery, if the mother and baby, both are having no problem.
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Early suckling provides warmth, security and colostrum, the baby s first
immunization. Although little in amount, the first milk, colostrums, is most
suitable and contains a high concentration of protein and other nutrients, the
baby needs. It is rich in anti-infective factors and protects the baby from
respiratory infections and diarrheal diseases.

Mothers should be demonstrated about the techniques of breast feedings.

Rooming-in or bedding-in should be done with infant and mother as soon as
possible to prevent separation. Mother should be advised for exclusive
breastfeeding up to 6 months and as demand feeding.

No food or drink other than breast milk should be given to neonates. No water,
glucose water, animal milk, gripe water, indigenous medicines, vitamins and
minerals drops or syrup should be given. No bottle and pacifier are allowed.

In case of preterm babies or sick babies, being in special care unit, they should
be fed with expressed breast milk. Nursing staff is responsible to ensure that
nothing except breast milk is given. Mother should be instructed to assess the
indicators of adequacy of breastfeeding and importance of increasing her own
dietary intake with extra 550 cal and to drink fluids in response to her thirst.
Rest and relaxation of mother are important for recovery from delivery and
successful lactation in postnatal period.

 BABY FRIENDLY HOSPITAL INITIATIVE

Since 1993 WHO’ s efforts to improve infant and young child nutrition have
focused on promoting breast feeding. It has been calculated that breast feeding
could prevent deaths of at least one million children a year. A new “baby-
friendly hospital initiative” (BFHI), created and promoted by WHO and
UNICEF, has proved highly successful in encouraging proper infant feeding
practices, starting at birth. BFHI is supported by the major professional medical
and nursing bodies in India. The global BFHI has listed ten steps which the
hospital must fulfil.
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 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 to initiate breastfeeding within half an hour of birth.
5. Show mothers how to breast-fed 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. Practice rooming-In. Allow mothers and infants to remain together 24
hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers ( also railed 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.

Indian hospitals are till in early stages of joining this movement. The National
BFHI task force was formed in 1992, towards the efforts to improve the
breastfeeding practices. Task force comprising of Government of India,
UNICEF,WHO and professional organizations (TNAI, BPNI, NNF, IMA,
FOGSI, IAP, CMAI, CHAI, IBFAN, ACASH) is working for evaluation of
breastfeeding practices in the hospitals and appropriate certification as ‘Baby
Friendly Hospital’. The certificate needs re-recognition on every two years to
ensure the standard and quality for successful breastfeeding. Besides promotion
of breastfeeding, baby friendly hospital initiative in India also proposes to
provide:

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  Improved antenatal care
 Mother friendly delivery services
 Standardized institutional support of immunization
 Diarrhea management
 Promotion of healthy growth and good nutrition
 Widespread availability and adoption of family planning.

Government of India has made significant efforts to promote and protect

breastfeeding by enacting a law ‘The Infant Milk Substitutes, Feeding Bottles
and Infant Food Act, 1992’. The act prohibits advertizing of infant milk
substitutes (IMS) and feeding bottles to public, free sampling, hospital
promotion and gifts of samples of IMS to health workers. Violation of the act
can lead to fine or imprisonment.

 WEANING

Weaning a baby from the breast or the bottle starts from 4-6 months. From
about 4-6 months old, baby needs more iron and other nutrients like Vitamin D
and Vitamin C that milk alone cannot give. The idea of weaning is the process
of gradual introduction to a wide range of ‘non milk’ foods so that by age of
one, baby will be joining in family meals.

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 Nutritional Balance
Nutritional Balance

More active Introduce more

dietary Items
Advantages of
Wearning

Child growth
Eat and enjoy
foods

Improve self
confidence

Fig no: 2 Advantages of weaning

Weaning is a transition form breast milk or formula milk to solid foods. It is

divided into the following stages:
Stage 1: Babies are usually ready to start on solid foods between 4 – 6 months.
Stage 2: 6 – 9 months.
Stage 3: 9 – 12 months.
Begin with smooth textures, mashed, minced, chopped, finger foods and finally
family foods.

Stage 1 : From 4 – 6 months

During the first couple of weeks of weaning, baby needs to learn that foods
have different textures and taste, and that it doesn’t come in continuous flow.
Start off with:
- Baby should be still having 600ml of breast or infant formula milk daily.

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- Starchy foods: Initially cereal is used such as baby rice
- Mashed, pureed, starchy vegetables are also suitable e.g. – potato, carrot,
sweet potato,. Try combining some of these foods together.
- Vegetables and fruits : soft cooked pureed vegetables and fruits are
suitable e.g. : apple, banana, pear, mango and chickoo. (Do not add sugar)
- Non fibrous vegetables e.g. cauliflower, pureed spinach.
Remebers:
1. The air is to get the baby used to taking food from a spoon-Start with
teaspoonful (quantities will be small) and milk will still be major sources of
nutrients).
2. Foods should be not be salted or sweetened.
3. Don’t press food on your baby- If the food doesn’t seem to be wanted,
wait and try again another day.
4. To try the food after a milk feed or in the middle of one.
If food is hot, make sure you stir it and test it again.

Stage 2 : From 6 – 6 months

- Gradually increase amount of food, give either before or milk feed.

- Continue 500-600ml breast or infant formula milk.
- Dairy products: Cow’s milk may be used to mix solids. Cheese may be
given as finger foods.
- Starchy goods 2-3 servings daily : introduce wheat based cereals, ragi
porridge
- Vegetables : 2 servings
- Raw soft fruits and vegetables may be given as finger foods e.g. – soft
cooked strips of carrot, Cooked green beans, soft banana and pear, Apple stew,
Spinach and tomato soup.
- Meat and alternatives – 1 serv. Chopped hard cooked egg may be used as
finger foods.

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Remember:
1. Introduce lumpy foods 6-7 months
2. Introduce feeding from the cup.
3. Encourage different textures and stronger tastes.
4. Food should not be salted or sweetened
5. Encourage a savoury preference to sweet.
Some meals to try:
Breakfast: porridge of rice or suji (rave) or dahlia or mashed banana
Lunch : minced chicken with vegetables and potato or khichri (gruel of rice and
dal with vegetables and potato) or soft ripe peeled pear or apple.
Dinner : mashed boiled sweet potato with carrots with cauliflower.

Stage 3 : From 9 – 12 months

- Continue 500 – 600ml – breast milk or infant milk formula daily.

- Dairy products : To continue to use cows milk to mix with solids. Hard
cheese used as finger feeds.
- Starchy foods : 3-4 servings daily
- May be normal adult texture.
- Vegetables and fruits : 3-4 servings
- Courage lightly cooked or raw foods. Chopped or finger is suitable, e.g.
pear, apple, banana and melon.
- Eat and alternatives : to try mixture of different vegetable and starchy
foods, dal and rice of and chicken.

From 1 year

Minimum of 350 ml milk daily or 2 Servings of dairy products e.g. curd,

Dairy products : Whole cows milk may be now used as a drink.
Starchy foods : minimum 4 servings daily.

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Vegetable and fruits : minimum 4 servings daily.
Remember : child may now take almost all that you cook for your regular
meals.

for successful weaning

Now plenty of time for feeding, particularly at first. Those time of the day when
both mother and child are relaxed with the small amounts of food and more
frequently produce new foods mixed with familiar foods not to get upset if the
baby refuses food. Take the food away and try again later.

 INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)

Resent the most important scheme in the field of child welfare is the ICDS
scheme. The aim for the scheme was prepared by the department of social
welfare in 1975. Program was initiated for the welfare of the children and
development of human resources for the preventive and development effort
through a integrated package services. The aim of the program are children up
to 6 years, adolescent girls (11-18 years), pregnant on nursing mothers and
women of 15-45 years.
ICDS scheme is working at village level in rural areas and also in urban and
tribal areas. In 1975, number of ICDS projects was only 33, which was started
on experimental basis. At present, the ICDS projects are functioning in 5422
blocks all over the country. The Kishori Shakti Yojna, Adolescent girls scheme
is sanctioned in 2000 ICDS blocks as special interventions for the benefits of
3.51 lakhs adolescent girls in the age group of 11 to 18 years. NGOs are also
involved in running anganwadi centers in 67 ICDS projects. World Bank
assisted ICDS projects are also working in some states.

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Fig.no: 3 Logo of ICDS
Objectives
The objectives of the ICDS scheme are :
 To improve the nutritional and health status of children in the age group 0
to 6 years.
 To lay the foundations for proper psychological and social development
of the child
 To reduce mortality, morbidity, malnutrition and school drop out .
 To achieve an effective co-ordination of policy and implementation
among the various departments working for the promotion of child
development.
 To enhance the capability of mother and to provide nutritional needs of
the child through proper nutrition and health education.

To achieve the above objectives the following package services are provided to
different categories of beneficiaries.

For children less than 3 years

 Supplementary nutrition
 Immunization
 Health check-up
 Referral services

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For children in age group of 3 to 6 years
 Supplementary nutrition
 Immunization
 Health check-up
 Referral services
 Non-formal preschool education

For adolescent girls 11 to 18 years

 Supplementary nutrition
 Nutrition and health education

For pregnant women

 Health check-up
 Immunization against tetanus
 Supplementary nutrition
 Nutrition and health education

For nursing mothers

 Health check-up
 Supplementary nutrition
 Nutrition and health education
Other women of 15 to 45 years age group
 Nutrition and health education
Delivery of services
The services are delivered by the Anganwadi worker (AWW) at the ICDS
centre for about 1000 population. Se is assisted by a local women who is
usually unskilled person. AWW has 4 months training in fundamentals of child
development, nutrition, immunization, personal hygiene, environmental

21
sanitation, antenatal care, breastfeeding care and treatment of common day to
day illness, identification and management of at-risk children, preschool
education, functional literacy and record keeping.
The Activities of AWW are supervised by a supervisor or Mukyasevika, who is
a graduate and having special training for two months. Each supervisor is
responsible for 20-25 AWWs. The child development project officer (CDPO),
is the in charge of ICDS projects, supervises the activities of four supervisors.
ICDS scheme is an important aspect of child welfare to improve the health,
nutrition, and educational status of the under privileged children and mothers.
 Supplemntary nutrition

Given to children below 6 years, nursing and expectant mothers fro low income
group. Air is to supplement nutritional intake as follows:
a) each child 6-72 months of age to get 500 calories and 12-15 grams of
protein.
b) severely malnourished child 6-72 months to get 800 calories & 20-25
grams protein.
c) each pregnant and nursing woman to get 600 calories and 18-20 grams of
protein.
 Nutrition and health education
 Nutrition education and health education is given to all women in the age
group of 15-45 years, giving priority to nursing and expectant mothers. It is
imparted by specially organized courses in village during home visits by
anganwadi workers.
 Immunization
Immunization of children against 6 vaccine preventable diseases being done,
immunization against tetanus is recommended for expectant mothers.

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 Health check up
This includes antenatal care of expectant mothers, post natal care of nursing
mothers & care of newborn, care of newborn under 6 years of age. Besides
immunization, expectant mothers are given iron and folic acid tablets along with
folic acid supplements. A minimum of three physical examination are done
high risk mothers are referred to appropriate institution for special care.
The health care of children under 6 years of age consists of:
 Record of weight and height of children at periodic intervals.
 Watch over milestones.
 Immunization
 General check up every 3 – 6 months to detect disease, malnutrition etc
 Treatment for disease like diarrhea, dysentery, respiratory tract infection
 Deworming
 Prophylaxis against vitamin A deficiency and anaemia
 Referral of serious cases to hospital

Health records : health records of the children, antenatal care and delivery card
etc are maintained. Card containing the health record of the child is given to the
mother.

 Non-formal pre-school education

Children between the ages 3-6 years are imparted non formal pre-school
education in an anganwadi in each village with about 1000 population. The
objective is to provide opportunities to develop desirable attitude, values and
behaviour pattern among children.
 UNDER – FIVE’S CLINIC
The concept of under five’s clinic is derived from the well baby clinic, for
comprehensive heath care of children below five years of age. This clinic

23
provides preventive services along with health supervision, treatment,
nutritional surveillance and health education.
The services provided by the clinic are set out in the symbol, which has been
proposed for under fives clinic in India.
The under five clinic is represented by traditional logo of a triangle with four
internal triangles and an outer enveloping triangle.

Care in
illness

Adequate Immuniza
tion
nutrition

Fig.no: 4 Symbol for under-five clinic

The apex of the large triangle represents care in illness, the left triangle
represents adequate nutrition, the right triangle represents immunization and the
central red triangle represents family planning. The line bordering the big
triangle represents health teaching to the mother.
 Care in illness
It includes:
 Diagnosis & treatment of :
24
 Acute illness, e.g. oral rehydration therapy
 Chronic illness including physical, mental, congenital and acquired
abnormalities
 Disorders of growth and development
 X-ray and laboratory services
 Referral services.
Care and treatment of sick children are rendered by the trained health worker on
the basis of the felt need of the mothers. Research studies have shown that 70 to
90 percent the care of sick children can be managed but the trained nurses with
effective training and responsibility for managing the child health care service.

 Adequate nutrition

Adequate nutrition is vital for growth and development of children, the health
worker should ensure about adequate breast feeding, weaning and balanced diet
of the under five children.
One of the basic activities of the under fives clinic is growth monitoring. It is
done by weighing the child periodically at monthly intervals during the first
year, every 2 months during the second year and every 3 months thereafter up to
the age of 5 to 6 years. The child’s weight is plotted on Road to Health Card as
growth curve which helps to detect early onset of growth failure.
Health check ups are done every 3 to 6 months by physical examination of the
child and appropriate laboratory tests. The child health card is maintained
which assist to identify at risk children who can be enlisted for special care and
referral for better treatment..
 Immunization
Immunization of children against vaccine-preventable diseases is an important
aspect of under clinics. Immunization of six killer diseases, viz. tuberculosis,
25
diphtheria, pertussis, tetanus, poliomyelitis and measles, are administered as per
national immunization schedule recommendation. The health worker should
motivate and promote the immunization acceptance to prevent morbidity,
mortality and disability hazards by these six killer diseases.

 Family Planning
Family planning program is successfully conducted through these clinics. The
mothers attending the clinic receive counseling with different aspects of family
planning practices which is a significant concern for the health and well-being
of the child.

 Health Education
Health education to the mother is an essential and compulsory activity of the
under fives clinic. The mothers should receive the information on various
aspects of child care and child rearing practices. Preventive measures against
malnutrition ARI, diarrhea, tuberculosis, worm infestations etc should be
informed to the mothers to improve awareness about the disease and its
prevention.

 SCHOOL HEALTH SERVICE

According to modern concept, school health service is an economical and
powerful means of raising future generation.
The beginning of school health service in India dates back to 1909, when for the
first time medical examination of school children was carried out in Baroda
city.
Objectives
 Promotion of positive health
 Prevention of diseases
 Early diagnosis, treatment & follow up of defects
26
 Awakening health consciousness in children
 The provision of healthful environment
Aspects of school health service
 Health appraisal of school children & school personnel
Consists of periodic medical examinations & observation of children by the
class teacher. The school health committee in India recommended medical
examination of children at the time of entry and entry and thereafter every 4
years.
 Remedial measures & follow up
Remedial measures should be followed by appropriate treatment and follow up.
Special clinic should be conducted exclusively for school children at the
primary health centres in the rural areas and in one of the selected school or
dispensaries for a group of about 5000 children in the urban areas.
 Prevention of communicable diseases
Communicable disease control through immunization is the most emphasized
school health function. a record of a immunization should be maintained as part
of the school health record.
 Healthful school environment
The school building, site & equipment are part of the environment therefore is
necessary for the best emotional, social and personal health of the pupils.
Schools should also serve as demonstration centres of good sanitation.
 Nutritional services
Mid-day school meal : in order to combat malnutrition and improve the health
of school children they are provided with good nourishing meal.
Applied Nutrition Program : UNICEF is assisting in the implementation of the
Applied nutrition program in the form of implements, seeds, manure etc. in
developing school gardens.

27
 First aid & emergency care
Teachers are carrying out the first aid program & they should be trained during
teacher training program e.g. accidents, medical emergencies like
gastrocenteritis, epileptic fits.
 Mental health
The mental health of the child affects his physical health and the leaning
process, Juvenile delinquency, maladjustment and drug addiction are major
problems. The school is the most strategic place for shaping the child’s
behavior and promoting mental health. The school teacher has both a positive
role.
 Dental health
Dental caries and periodontal disease are the two common diseases in children.
A school health program should have provision for dental examination, at least
once a year.
 Eye Health services
Schools should be responsible for the early detection of refractive errors,
treatment of squint and detection and treatment of eye infection.
 Health education
The most important element of school health program is health education. The
goal is to bring about desirable changes in health knowledge, in attitude and in
practice. Health education about personal hygiene, environmental health,
family life etc.
 Education of handicapped children
The ultimate goal is to assist the handicapped child and his family so that the
child is able to reach his maximum potential &lead as normal as possible.
 School health record
Cumulative health record of each student should be maintained. Purpose is to
have cumulative information on the health aspect of school children in order to
give continuing intelligent health supervision.
28
IV. AIMS/ OBJECTIVES OF PREVENTIVE PEDIATRICS
1. Growth monitoring: Growth monitoring is oriented to the individual
child, and is a dynamic measure of its health from month to month. On normal
nutrition and the means to promote continued growth and good health. It
requires enrolment of the infant at an early stage, preferably before 6 months.
Regular monthly participation is crucial to detect early onset of growth
faltering. Assessment of physical growth can be done by anthropometric
measurements and the study of velocity of physical growth. Measurement of
different growth parameters is the important nursing responsibility in child care.
The criteria for assessment of physical growth are mainly weight, length or
height, head circumference, chest circumference and mid upper arm
circumference. Assessment of body mass index, body ratio, fontanelle closure,
skin fold thickness, dentition and bone age also used as parameters for
evaluation of physical growth.
2. Promotion of breast feeding: Breastfeeding is the best natural feeding
and breast milk is best milk. The basic food of infant is mother’s milk.
Breastfeeding is the most effective way to provide a baby with a caring
environment and complete food. It meets the nutritional as well as emotional
and psychological needs of the infant. But recently there is tendency to replace
the natural means of infant feeding and introduction of breast milk substitutes.
So breastfeeding deserves encouragement from all concerned in the welfare of
the children. Providing health education regarding the importance of breast
feeding is necessary for the promotion of breast feeding.
3. Oral Rehydration: Oral rehydration therapy (ORT) was developed as a
safer, less expensive, and easier alternative to intravenous fluids. Oral
rehydration solution contains glucose (a sugar) and electrolytes (sodium,
potassium, chloride) that are lost in children with vomiting and diarrhea.
Various rehydration solutions are available. Parents should check with a
healthcare provider to determine which solution is preferred. A child who is

29
moderately or severely dehydrated needs to be evaluated by a healthcare
provider.
4. Immunization: Immunization is a process of protecting an individual
from a disease through introduction of live, or killed or attenuated organisms in
the individual system. It is one of the best buys in community health and one of
the most cost-effective health interventions. Immunization of six killer diseases,
viz. tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles, are
administered as per national immunization schedule recommendation. The
health worker should motivate and promote the immunization acceptance to
prevent morbidity, mortality and disability hazards by these six killer diseases.
5. Nutritional surveillance: Nutritional surveillance, can be carried out on
a representative sample of children in the community. It gives a reliable idea of
the overall nutritional condition of village ( or area) A-whether it is good or bad,
is better or worse than that of village B or C (and so requires supplies and
personnel), and whether it is improving or deteriorating with time. It can help to
diagnose malnutrition and assess the impact of occurrence like drought or
measures designed to alleviate malnutrition in the community at large.
Adequate nutrition is vital for growth and development of children. The health
worker should ensure about adequate breastfeeding, weaning and balanced diet
of the under-5 children. Almost all nutritional disorders like PEM, anemia,
rickets, nutritional blindness occur in this age group. Attempts to be made to
identify early onset of growth failure and malnutrition. One of the basic
activities of the under-fives clinic is growth monitoring. It is done by weighing
the child periodically at monthly intervals during the first year, every 2 months
during the second year and every 3 months thereafter up to the age of 5 to 6
years.
6. Regular health checkup: Medical examination to be done for each and
every child at the time of every 4 years or less. Basic investigations like urine,
stool and blood tests should also be done. Recording of weight and height

30
should be done quarterly and vision testing annually. Daily morning inspection
helps to detect any deviation from normal health status or changes in child s
appearance or behavior that suggest illness or improper growth and
development. A teacher should be trained about the common health problems of
children during basic training and later in-service training courses. Appropriate
treatment and follow-up should be arranged after medical check-up. Special
attention should be paid to dental, eye and ENT problems. There should be
provision for referral along with further investigations and treatment of the
specific problem.
V. ASPECTS OF PREVENTIVE PEDIATRICS
Preventive paediatrics comprises efforts to avert rather than cure disease
and disabilities. It has been broadly divided into antenatal paediatrics and
postnatal paediatrics. The aims preventive paediatrics and preventive medicine
are the same: prevention of disease and promotion of physical, mental and
social well-being of children so that each child may achieve the genetic
potential with which he/she is born. The challenge of the time is to study child
health in relation to community, to social values and to social policy. This has
given rise to the concept of social paediatrics. Social paediatrics has been
defined as “the application of the principles of social medicine to paediatrics to
obtain a more complete understanding of the problems of children in order to
prevent and treat disease and promote their adequate growth and development,
through an organized health structure.
1. ANTENATAL PREVENTIVE PAEDIATRICS
It includes care of the pregnant mothers with adequate nutrition, prevention of
communicable diseases, preparation of the mother for delivery, breastfeeding
and mother craft training etc. Pre-pregnant health status of the mother also
influences the child health. Mother and child must be considered as one unit. It
is because during the antenatal period, the foetus is part of the mother. The
period of development of foetus in mother is about 280 days. During this

31
period, the foetus obtains all the building materials and oxygen from the
mothers blood, child health is closely related to maternal health. A healthy
mother brings forth a healthy baby; there is less chance for a premature birth,
stillbirth or abortion, certain diseases and conditions of the mother during
pregnancy are likely to have their effects upon the foetus. After birth, the child
is dependent upon the mother. At least up to the age of 6 to 9 months, the child
is completely dependent on the mother for feeding. The mental and social
development of the child is also dependent upon the mother. If the mother dies,
the child’s growth and development are affected (maternal deprivation
syndrome). In the care cycle of women, there are few occasions when service to
the child is not simultaneously called for. For instance, postpartum care is
inseparable from neonatal care and family planning advice. The mother is also
the first teacher of the child. It is for these reasons, the mother and child are
treated as one unit.
a. Antenatal aspects of preventive pediatrics
The term ··maternal and child health” refers to the promotive, preventive,
curative and rehabilitative health care for mothers and children. It includes the
sub-areas of maternal health, child health, family planning, school health,
handicapped children, adolescence, and health aspects of care of children in
special settings such as day care. The specific objectives of maternal and child
health are reduction of maternal, perinatal, infant and childhood mortality and
morbidity, promotion of reproductive health; and promotion of the physical and
psychological development of the child and adolescent within the family. The
ultimate objective of MCH services is life-long health.
 Antenatal care: Antenatal care is the care of the woman during
pregnancy. The primary aim of antenatal care is to achieve at the end of a
pregnancy a healthy mother and a healthy baby. Ideally this care should begin
soon after conception and continue throughout pregnancy.

32
 Antenatal visit: Ideally the mother should attend the antenatal clinic
once a month during the first 7 months; twice a month, during the next month;
and thereafter, once a week, if everything is normal. A high proportion of
mothers in India are from lower socio-economic group and many of them are
working women. Attendance at the antenatal clinic may mean loss of daily
wages. Consequently, it is difficult for them to attend the antenatal clinic so
often. In these cases, a minimum of 3 visits covering the entire period of
pregnancy should be the target. Further visits· may be made if justified by the
condition of the mother. At least one visit should be paid in the home of the
mother.
 Prenatal advice: A major component of antenatal care is antenatal or
prenatal advice. The mother is more receptive to advice concerning herself and
her baby at this time than at other times. The “talking points” should cover not
only the specific problems of pregnancy and child-birth but overflow into
family and child health care.
(i) DIET: Reproduction costs energy. A pregnancy in total duration
consumes about 60,000 kcal, over and above normal metabolic requirements.
Lactation demands about 550 kcal a day. Further, child survival is correlated
with birth weight. And birth weight is correlated to the weight gain of the
mother during pregnancy. On an average, a normal healthy woman gains about
12 kg of weight during pregnancy. Thus pregnancy imposes the need for
considerable extra calorie and nutrient requirements. If maternal stores of iron
are poor and if enough iron is not available to the mother during pregnancy, it
is possible that foetus may lay down insufficient iron stores. Such a baby may
show a normal haemoglobin at birth, but will lack the stores of iron necessary
for rapid growth and increase in blood volume and muscle mass in the first year
of life.
(ii) PERSONAL HYGIENE: Of equal importance is advice regarding
personal hygiene. (a) Personal cleanliness: The need to bathe every day and to
33
wear clean clothes should be explained. The hair should also be kept clean and
tidy. (b) Rest and sleep: 8 hours sleep, and at least 2 hours rest after mid-day
meals should be advised. (c) Bowels: Constipation should be avoided by regular
intake of green leafy vegetables, fruits and extra fluids. Purgatives like castor oil
should be avoided to relieve constipation. (d) Exercise: Light household work is
advised, but manual physical labour during late pregnancy may adversely affect
the foetus. (e) Smoking: Smoking should be cut down to a minimum. The
adverse effects of smoking range from low birth-weight to an increased risk of
perinatal death of the infant. (f) Alcohol: Evidence is mounting that alcohol can
cause a range of fertility problems in women. Heavy drinking has been
associated with a fetal syndrome (FAS) which includes intrauterine growth
retardation and developmental delay.(g) Dental care: Advice should also be
given about oral hygiene. (h) Sexual intercourse: This should be restricted
especially during the last trimester.
(iii) DRUGS: The use of drugs that are not absolutely essential should be
discouraged. Certain drugs taken by the mother during pregnancy may affect the
foetus adversely and cause foetal malformations. The classical example is
thalidomide, a hypnotic drug, which caused deformed hands and feet of the
babies born.
(iv) RADIATION: Exposure to radiation is a positive danger to the
developing foetus. The most common source of radiation is abdominal X-ray
during pregnancy.
(v) WARNING SIGNS: The mother should be given clear cut instructions
that she should report immediately in case of the fallowing warning signals: (a)
swelling of the feet (b) fits (c) headache (d) blurring of the vision bleeding or
discharge per vagina, and (f) any other unusual symptoms.
(vi) CHILD CARE: The art of child care has to be learnt. Special classes are
held for mothers attending antenatal clinics. Mother-craft education consist1oi

34
nutrition education, advice on hygiene and childrearing, cooking
demonstrations, family planning education, family budgeting, etc.
 Specific health protection:
(i) ANAEMIA: Surveys in different parts of India indicate that about 50 to
60 per cent of women belonging to low socio-economic groups are anaemic in
the last trimester of pregnancy. The major aetiological factors being iron and
thromboembolic phenomena in the mother.
(ii) OTHER NUTRITIONAL DEFICIENCIES: The mother should be
protected against other nutritional deficiencies that may occur, particularly
protein, vitamin and mineral especially vit A and iodine deficiency.
(iii) TOXEMIAS OF PREGNANCY: The presence of albumin in urine and
an increase in blood pressure indicates toxemias of pregnancy. Their early
detection management are indicated. Efficient antenatal care minimizes the risk
of toxemias of pregnancy.
(iv) TETANUS: If the mother was not immunized earlier 2 doses of adsorbed
tetanus toxoid should be given the first dose at 16-20 weeks and the second dose
at 20-24 weeks of pregnancy.
(v) SYPHILIS: Syphilis is an important preventable cause of pregnancy
wastage in some countries. Pregnancies in women with primary and secondary
syphilis often end in spontaneous abortion, still birth, perinatal death, or the
birth of a child with congenital syphilis. Syphilitic infection in the pregnant
woman is transmissible to the foetus.
(vi) GERMAN MEASLES: Ideally the infection should prevent during
pregnancy by preventing and controlling the disease in the general population.
(vii) PRENATAL GENETIC SCREENING: Prenatal genetic screening
includes screening for chromosomal abnormalities associated with serious birth
defects, screening for direct evidence of congenital structural anomalies, and
screening for direct evidence of congenital structural anomalies, and screening

35
for haemoglobinopathies and other inherited conditions detectable by
biochemical assay.
 Mental preparation
Antenatal care does not mean only palpation, blood and urine examination and
pelvic measurements. These are no doubt important aspects of antenatal care.
Mental preparation is as important as physical or material preparation.
Sufficient time and opportunity must be given to the expectant mothers to have
a free and frank talk on all aspects of pregnancy and delivery.
 Family planning
Family planning is related to every phase of the maternity cycle. The mother is
psychologically more receptive to advice on family planning than at other times.
Educational and motivational efforts must be initiated during the antenatal
period. If the mother has had 2 or more children, she should be motivated for
puerperal sterilization.
 Pediatric component
It is suggested that a pediatrician should be in attendance at all antenatal clinics
to pay attention to the under-fives accompanying the mothers.

4. POSTNATAL PREVENTIVE PAEDIATRICS

It include promotion of breastfeeding, introduction of complementary feeding at

appropriate age, immunization, prevention of accidents, tender loving care with
emotional security, growth monitoring, periodic medical supervision and health
check-up, psychological assessment, etc.

5. SOCIAL PREVENTIVE PAEDIATRICS

Social pediatrics has been defined as “the application of the principles of social
medicine to pediatrics to obtain a more complete understanding of the problems
of children in order to prevent and treat disease and promote their adequate
36
growth and development, through an organized health structure”. The challenge
of the time is to study child health in relation to community, to social values and
to social policy. This has given rise to the concept of social pediatrics. Social
pediatrics, like social obstetrics, covers a wide responsibility. It is concerned not
only with the social factors which influence child health but also with the
influence of these factors on the organization, delivery and utilization of child
health care services. In other words, social pediatrics is concerned with the
delivery of comprehensive and continuous child health care services and to
bring these services within the reach of the total community. Social pediatrics
also covers the various social welfare measures – local, national and
international- aimed to meet the total health needs of a child.
Preventive and social medicine, with its involvement in total community care,
and expertise in epidemiology and in the methodology of collection and
utilization of data relating to the community and the environment, makes an
indispensable contribution to social obstetrics and social pediatrics in the:
1 collection and interpretation of community statistics, delineating groups at
risk” for special care
2. correlation of vital statistics (e.g., maternal and infant morbidity and
mortality rates, perinatal and child mortality rates) with social and biological
characteristics such as birth weight, parity, age, stature, employment etc. in the
elucidation of aetiological relationships
3. study of cultural patterns, beliefs and practices relating to childbearing and
childrearing, knowledge of which might be useful in promoting acceptance and
utilization of obstetric and paediatric services by the community;
4. to determine priorities and contribute to the planning of MCH services and
programmes,
5. for evaluating whether MCH services and programmes are accomplishing
their objectives in terms of their effectiveness and efficiency.

37
Hitherto, obstetrics, paediatrics and preventive and social medicine were
operating in watertight compartments. The emergence of social paediatrics,
social obstetrics and their association with preventive and social medicine are
certainly new developments in contemporary medicine. In some Universities, a
chair of social paediatrics has also been established. The increasing coming
together of these disciplines augurs well for the provision of comprehensive
mother and child health care and family planning services as a compact family
welfare service.
VI. IMMUNIZATION
Immunization is on of the most cost effective health interventions known to
mankind. It is also true that immunization is the most successful, single, child
survival strategy. Immunization schedules are the basic framework for the
delivery of vaccines to individuals as well as the community as whole.
Prevention of disease is one of the most important goals in childcare. During
infancy and childhood, preventive measures against certain infectious diseases
are available. One of the most dramatic advances in pediatrics has been the
decline of infectious diseases during 20thcentury because of the widespread use
of immunization for preventable diseases. Immunization recommendation
changes because of advances in the field of immunology. 80% of the infants and
children are now immunized and preventing the spread of infectious diseases.
Before any immunizations are undertaken the parents should be questioned
regarding present and past immunization status and past responses of
immunizations. The parents should be fully informed concerning the reasons for
immunizations. They should also be informed of possible side effects and
adverse reactions. A record of immunization should be kept by the health
professionals as well as the parents for future reference.
IMMUNITY

Immunity is the function of the body that provides protection against infectious
diseases. The cells and molecules responsible for providing immunity comprise
38
the immune system. This system plays an important role in autoimmune
diseases and helps to fight against malignancy. There are two types of immunity
they are innate and acquired immunity.

1. TYPES OF IMMUNITY

Basic defence mechanisms are of two types: non-specific (innate) and specific
(adaptive). Both are equally important for the survival of the human being. Both
are interdependent in the ultimate goal of getting rid of what is ‘foreign’.

1) Innate immunity (Non-specific Immunity)

It is also known as innate or non-adaptive immunity. It is present in every

normal individual since birth and does not need prior exposure to the organism
nor is it specific against an individual organism. This is the oldest type of
immunity in evolution which helps the body control invading organism before
specific immune response is mounted and also helps the specific immune
response to augment its efficacy by acting as the final effector pathway. The
innate immunity occurs with in a short period when a person exposed to any
type of infection. It includes natural mechanical barriers such as skin
integument and mucosal linings, chemical barriers such as gastric acidity and
gut enzymes classical and alternate pathways of compliment systems, cytokines,
chemokines and interferon α, β, and γ, and the cells like macrophages,
neutrophils, dendritic cells, natural killer cells. The complement system is again
divided into two pathways, the classical and the alternate path way both acting
through a cascade of more than 19 proteins. Complements help in initiating the
inflammation and in sustaining the specific immune response and ultimate
killing of the organism.

2) Acquired immunity (Specific Immunity)

It can be divided into natural versus acquired, passive versus active and humoral
versus cellular. This occurs in the transplacental transfer of immunoglobulin
39
which offers protection to the newborn for a temporary period of time, it is not
fully active at birth and develops gradually after birth on repeated exposure to
the microbes in the surroundings. The most important cells of this arm include
the B lymphocytes, T lymphocytes, and their various subsets. On activation by
an antigen, the B cells proliferate and get converted to plasma cells, which, in
turn, produce antibodies. For effective production of antibodies B cells needs
the T cells which produced in the liver in fetal life and mature in bone marrows
in the humans. Besides its role as helper cells to induce better antibody
production by the B cells, the T cells are the most important cytotoxic cells ,
which helps in preventing invasion by and clearing of intracellular pathogens.

3) Humoral immune response

The antibodies consist of heavy chains and light chains. There are two types of
light chains, lambda and kappa chains; whereas, there are five different types of
heavy chains which identify the five types of immunoglobulins; lgG, lgM, IgA,
IgD and IgE. In this lgG, lgM, and IgA are protective against pathogens. The
IgE type may play a role against parasites and is also involved in allergies.

The B cells have immunoglobulin surface receptor, which binds with the
appropriate antigen present on the infective pathogen. The antigen and the
receptor complex are internalized and the antigen is processed within the cell.

During acute infection, IgM antibodies appear within few days and the presence
of IgM indicates recent infection. The lgM response is usually seen in Primary
response, is short lived and the titers of the antibodies are lower. The IgG
response usually picks up along with the IgM or after a few days and lasts for a
very long time. The IgA response depends upon the route and the type of
infection. Serum IgA is seen in organisms that invade from mucosa; whereas
surface IgA is classically seen with localized mucosal infections such as in
cholera.

40
4) Cell-mediated immunity

This type of immunity is transferable by the lymphocytes and not antibodies and
is mediated via T cells. They are called T cells as they mature in the cells.
Though called cell mediated immunity, it often involves the role of soluble
chemicals called cytokines, which are secreted and react upon T cells
themselves besides the B cells and macrophages.

The T cell lymphocyte is a very important cell in the immune response. It has T
cell receptor (TCR) with α and β chains, which binds with the antigen processed
and expressed on the antigen-presenting cell along with the MHC class I or II
antigens. It also has receptors for co-stimulatory factor and for the various
cytokines and chemokines released in the surrounding. It has many subsets,
which carry out different functions. These cells are in circulation and in the
lymphatic vessels. There are two essential types of T cells depending on the CD
molecules expressed on the surface of the T cell, CD4+T and CDS+ T cells. The
CD4+ T cells react cells MHC II on the APC, while CD8+ T cells react with the
MHC I. The CD4+ T cells are called T helper cells and CDS+ T cells are also
called cytotoxic T cells.

The CD4+ T cells are of two subtypes: Thl and Th2 cells. The Th2 cell response
is the major factor for the stimulation of B cells, and for the switch in the
production from IgM to other immuno-globulins, which occurs in role presence
of IL4. The Toi cells are responsible for the delayed hypersensitivity reaction
and occur in the presence of interleukin-12 (IL-12) and IL-18. Besides this, the
types of cytokines produced by Th1 and Th2 cells are also different. The CDB+
T cells recognize and target the infected cells in the body and hence, are called
cytotoxic T lymphocytes. This was first demonstrated with virus-infected cells
and later on with cells infected with bacteria as well as parasites.

41
5) Passive immunity

Passive immunity is specific immunity which, is transferred passively to the

recipient. It gives readymade immunoglobulins, which help fight infection
immediately. However, it is for a temporary period and it wanes after a few
weeks to a few months depending upon the half-life of the transferred
immunoglobulins. Besides the natural transplacental passive transfer of the
immunoglobulins in the newborn, the other examples of the passive immunity
are infusing immunoglobulins in the person to protect him for a specific disease.

 Transplacental Passive Immunity

Immunoglobulins are transferred predominantly in the last trimester and are

mainly of IgG type. This means that at birth, the child will have similar type of
antibody pattern as the mother. This protects the child for the first few months
till the time that he develops his own immunity after repeated exposure to
various antigens after birth. The half-life and hence the protection offered will
depend on the half-life of the specific antibody, e.g. the antibody against
poliomyelitis does not protect for more than 4-6 weeks ( the time of starting the
polio vaccination in the baby), whereas the anti-measles antibody protects the
child till 6-9 months (the reason for delaying the measles vaccine till 9 months).
Not only does the passive immunity protect the newborn/infant against the
specific diseases, it also interferes with the immune response to the concerned
vaccine if given in the presence of maternal antibody

 Acquired passive immunity

Immunoglobulins can be passively transferred by giving immunoglobulin

preparation intramuscularly or intravenously. There are three types of
preparations,

1. Pooled human immunoglobulin preparation

2. Homologous humen hyperimmune globulin preparation
42
3. Heterologous human hyperimmune globulin preparation

1. Pooled Human lmmunoglobulins

This is prepared by Pooled Plasma from more than 100 healthy donors and
fractionation of this plasma to produce the final product, which is available as
intramuscular (IM) preparation as well as intravenous (IV) preparation. It is
used in many autoimmune disorders and passive prophylaxis for measles or
hepatitis A infection.

2. Homologous human hyperimmune Globulins

This is obtained by pooling plasma from specific donors who have high titers of
a specific antibody either due to repeated past natural exposure or due to
vaccination. This preparation serves to protect against a specific disease

3. Heterologous Human Hyperimmune Globulins

It is obtained from animals mainly horse or rabbit who are hyperimmunized by

repeated vaccination against the concerned disease and then collecting plasma
which is fractionated to obtain pure product. Being an animal product it can lead
to severe allergic reactions including anaphylaxis, anaphylactoid reactions or
serum sickness.

6) Active immunity

Active immunity is developed by stimulating the immune system by antigens,

which can lead to specific humoral or cellular immune response or both. It can
happen in two ways, either by exposure to the wild pathogen naturally where
the immunity develops after the person suffers from the disease which has
chances of morbidity and even mortality or by exposure to the antigens given as
vaccines where the person has less morbidity and the person becomes immune
without much suffering. Not all natural diseases lead to protective immunity; in

43
naturally occurring tetanus or typhoid, repeated clinical courses are known
unless vaccination is done. However, most of the time natural disease leads to
strong protective immunity, which probably lasts lifelong, e.g. in measles or
varicella. Vaccination, on the other hand, is introduction of antigens with the
purpose of inducing immune response without leading to clinical diseases.

VACCINES

Vaccines can be live or inactivated and both can be bacterial or viral. Live
vaccines are attenuated live organisms, which have immunogenicity without
pathogenicity, Inactivated vaccines can kill the whole organism or a fraction of
it. Fractional vaccine also includes toxoids (Diphtheria or tetanus toxoids) and
subunit vaccine such as hepatitis B vaccine. They also include proteins or
polysaccharides, which again can be unconjugated (Vi typhoid vaccine) or
conjugated (Hib vaccine).

1. Live Vaccines

These are pathogens, which are modified in such a way that they lose their
pathogenicity without altering their immunogenicity. Most live vaccines are
viral vaccines such as measles, MMR [( measles, mumps, and rubella ( German
measles)], varicella, and oral polio vaccine (OPV). Some bacterial vaccines too
are live vaccines such as Baccilus Calmette-Guerin (BCG) and oral Ty2Ia
typhoid vaccine. The pathogen is attenuated by serial passage of the wild type in
tissue cultures or animals. The live vaccine multiplies inside the body after
administration and stimulates the immune system. Injectable live vaccines thus
need only one dose for development of long-term immunity, e.g. measles or
MMR vaccine. The immunity is maintained subsequently, probably, by
subclinical infections. However, when such vaccine is used universally, it will
reduce or abolish the natural transmission leading to less chance of repeated
subclinical exposures. This may lead to waning immunity after many years and

44
may need artificial boosting, e.g. MMR where we now know that 2 dose are
required to maintain long-term protection. Live vaccines given orally such as
OPV or Ty2la typhoid vaccines need multiple doses to induce lasting immunity.
Another problem with live vaccines is side effects such as vaccine-induced
disease, e.g. OPV-induced paralysis, which occurs due to reversal of the
attenuated strain back to a virulent strains. Lastly, live vaccines are
contraindicated in immune compromised individuals as the organism can
replicate in such cases leading to disease. Attenuated and genetically modified
viruses are used as vectors to introduce other antigens.

2. Inactivated vaccines (Killed vaccines)

Inactivated vaccines are either kill the whole organisms such as whole cell
typhoid vaccine or pertussis vaccine, or a fraction of it such as in acellular
pertussis vaccine, toxoids such as tetanus toxoid, subunit vaccine, e.g. surface
antigen of hepatitis B or polysaccharide such tetanus toxoid, subunit vaccine,
e.g. surface antigen of hepatitis B or polysaccharide such as pneumococcal
vaccine. As the vaccine does not replicate in the body, it does not lead to
clinical disease and is safe even in immune compromised host. 7 1he immune
response is not disturbed by the presence of previous antibodies; hence, these
vaccines can be started early in life, e.g. diphtheria, pertusis, and tetanus (DPT)
vaccination. The first dose usually does not lead to protection and only primes

The immune system subsequent doses lead to primary immune response, which
protects the individual for a short time. Subsequent repetition of doses leads to
boosting effect and long-term immunity. Hence, these vaccines need multiple
primary and booster dose.

1. BCG VACCINATION

History

Robert Koch discovered the tubercle bacillus.

45
1908-1921: The French scientists, Calmette and Guerin, began attenuating a
virulent strain of M. Bovis with a view to develop a vaccine against TB. After
231 subcultures over a period of 13 years, they were able to evolve a strain
known thereafter as ‘Bacillus Calmette-Guerin’ tor BCG). This strain was non-
virulent for humans but retained its capacity to induce an immune response.

1924: The bacillus was declared incapable of 14-reverting to virulent form by

Calmette.

1927: First human BCG vaccination.

1928: BCG strains were declared to be harmless to animals and man by the
League of Nations.

1929-1930: The Lubeck tragedy- 72 children died from oral BCG preparation
contaminated with a virulent strain.

1939: Multiple puncture technique was developed.

1947: Scarification technique was developed

1948: Recognition of value of BCG came in 1948 when tuberculosis workers

from all over the world accepted it as a safe preventive measure. BCG
vaccination program in was started in 1948 in Madanpalle (Tamil Nadu) and in
the same year the BCG vaccine Laboratory was established in Madras Chennai).

1948-1974: WHO and UNICEF campaigns l. 5 billion vaccinations carried out

1948-1997: Yearly increase in BCG vaccination estimated approximately to be

50-100 million.

Types of vaccine

Liquid (fresh) vaccine and the freeze- dried vaccine are the two types of BCG
vaccine. Freeze-dried preparation is relatively a more stable preparation with
vastly superior keeping qualities. The present-day vaccines are distributed in
46
freeze-dried forms. The bacilli used for the vaccine production are derived from
the original Calmette strain of BCG.

Storage

This vaccine remains potent for two years, if store at -20°C. Undiluted vaccine
when stored at 2-4°C retains its potency for up to 6 months. When stored at 4-
8°C, it should be used within a week. Strict maintenance of cold chain is
essential. It should be wrapped in black paper/ cloth and supplied in dark
colored ampoules.

Reconstitution

Ampoules of freeze-dried vaccine are sealed under vacuum. They must be

opened carefully by gradually filling at the junction of the neck and the body of
the ampoule so that air does not rush in to cause spillage. Normal Saline is the
recommended diluents, as distilled water may cause irritation. The diluents can
be stored at room temperature, but it should be cooled immediately before use.
The reconstituted vaccine should be used within 4 hours. During this time, it
should be protected from light and heat. The left over products after a given
immunization session must be discarded.

Dosage

• O. l mg in 0.1 ml. Dose remains same for all ages. The currently available
BCG vaccine brand is prepared by Serum Institute of India

Age of vaccination

BCG vaccination should be administered at birth to before one year of age if

skipped at birth.

47
Prevention of disease

Immunity against tuberculosis is mediated through complex cellular mechanism

in which macrophages and T lymphocytes have predominant role. Tuberculin
reactivity cannot be passively transmitted by injecting serum having antibodies
but by injecting cells from an immunized animal. BCG has a protective effect
against the severe forms of disease such as meningus and tuberculosis.

Administration

It should be injected intradermally using a ‘Tuberculin’ syringe. The syringe

and needle technique remains the most precise way of administering the desired
dose. It should be administered just above the insertion of deltoid muscle. If it is
injected too high, too anterior or too posterior, the chances of development of an
ipsilateral axillary lymphadenopathy are said to increase. A satisfactory
injection should produce a wheal 5 mm in diameter. Care must be taken to
avoid contamination with an antiseptic or detergent. Cleaning with sterile water
is enough. If alcohol swab is used to clean the skin, it must be allowed to
evaporate before the vaccine is administered.

Phenomena Seen after BCG Vaccination

Day 0: AboutS-8 mm of wheal develop over the site of injection, which gets
absorbed in 20-30 minutes; rubbing/hot fomentation at the injection site should
be avoided

2-3weeks: A papule develops at the site of vaccination

3-6 weeks: Papule increases slowly in size to reach a diameter of 4-8 mm

6-12 weeks: Papule subsides; a shallow ulcer may develop which may be
covered with a crust. This will heal within 6-12 weeks and will leave behind a
small scar, approximately 5 mm in diameter. Tuberculin positivity usually
develops within 6-8 weeks.
48
Complications with lntradermal BCG

Local and localized: swelling, pain at site, ulcer, abscess, regional

lymphadenitis, (non-sappuratiee and suppurative) and osteomyelitis.

Regional: Mesenteric adenitis, otitis, distant abscesses, hepatosplenomegaly

Disseminated: Distinctly unusual and is usually associated with severe

depression of cell-mediated immunity.

Post-BCG syndrome: Local chronic cutaneous lesions (e.g. keloids), acute

cutaneous eruption (e.g.erythema nodosum) and ocular lesions. BCG
lymphadenitis is the most common complication of BCG vaccination, occurring
in 0.1-4% of the vaccinated children.

Contraindications to BCG Vaccination

BCG should not be given in the following conditions

 Severe combined immunodeficiency

 Patients on prolonged immunosuppressant
 HIV-infected patients who are symptomatic or if CD41 is less than 25%

Do’s and Don’ts in BCG

 Mother can feed the baby after vaccination

 Give oral medicines to reduce pain
 Inspect the area for developing papules
 Check the wheel developed at the injection site is 5-8mm or more.
 Do not rub the area after vaccination
 Do not give hot application at the injection site
2. PENTAVALENT VACCINE

It is a 5 in 1 combination vaccine which includes diphtheria, pertussis, tetanus,

hepatitis B vaccine and hemophilus influenza B vaccine.
49
1. Diphtheria

Diphtheria vaccine is a toxoid (DT), containing diphtheria toxin inactivated by

formalin and adsorbed on aluminium hydroxide that acts as an adjuvant. The
quantity of toxoid contained in a vaccine is expressed as its limit of flocculation
(Lf) content. The most commonly used vaccine is a combination vaccine
containing 20-30 Lf of DT, 5-25 Lf of tetanus toxoid (TT) and >4 IU of whole
cell killed pertussis. To ensure protection against diphtheria, vaccination should
begin within a few weeks after birth and requires multiple doses. Primary
immunization with 3 doses given 4-8 weeks apart induces satisfactory antitoxin
response to DT and TT in 95-100% infants.

2. Pertussis
Pertussis (whooping cough) is an important global cause of infectious
morbidity, with an estimated annual occurrence of 16 million cases, chiefly in
developing countries. While the incidence of pertussis has declined dramatically
following EPI coverage, the infection continues to be endemic even in countries
with high vaccination rates. The disease usually affects infants and
unimmunized adolescents; those <6-month-old have the highest case fatality
rate. Natural infections and immunization induce immunity lasting 4-12 yr.
Individuals in which pentavalent is contraindicated should complete the
immunization schedule with DT, that contains the same doses of DT and TT as
pentavalent, but is devoid of the pertussis component. DT is recommended for
use up to the age of 7 yr, beyond which test dose must be used.
3. Tetanus Toxoid
Extensive routine immunization of pregnant women with two doses of TT has
led to a decline in the incidence of neonatal tetanus, previously an important
cause of neonatal mortality. Immunizing pregnant women with two doses, with
the second dose administered at least 2 weeks prior to delivery, provides passive
immunity to the baby due to the transplacental passage of IgG antibodies.

50
Tetanus toxin is inactivated by formalin to make tetanus toxoid (TT) and
adsorbed onto aluminium salts to enhance its immunogenicity. Each dose of IT
vaccine contains 5 Lf of the toxoid. The vaccine is heat stable and remains
potent for a few weeks even at 370c. Since tetanus may occur at any age,
primary immunization should begin in early infancy. Tetanus toxoid is
administered with the combination of pentavalent vaccine. TT should not be
administered after every injury if immunization is complete and last dose was
received within last 10 yr.
4. Hepatitis B vaccine
India has intermediate endemicity for hepatitis B virus (HBV), with about 4%
individuals being chronic carriers of the virus. HBV is the leading known cause
of chronic hepatitis, cirrhosis and hepatocellular carcinoma. The current
hepatitis B vaccine is a highly purified vaccine produced by recombinant DNA
techniques in Yeast species and contains aluminium salts as adjuvant. Each
pediatric dose of 0.5ml contains 10 µg of antigenic component. Hepatitis B
surface antigen (HBsAg) screening should be offered to all pregnant women.
5. Hemophilus Influenza Vaccines

H, influenza type 'B’ (Hib) is an important cause of meningitis and pneumonia

among children below five years of age. The WHO recommends inclusion of
Hib vaccine in routine infant immunization programs. Hib vaccine is now
available in combination with pentavalent vaccine.

Routinely, Hib vaccine can be given at the age of 2 months and second dose
after 6 weeks along with pentavalent vaccine. The dose is 0.5 ml and given in
intramuscular route with no known adverse reactions or absolute
contraindications except hypersensitivity to the vaccine. When Hib
immunization has not been started by the 7 months of age, only 2 doses are
given and only one dose is given to unimmunized children of aged 15 months or

51
more. For the children more than 5 years of age this vaccine is indicated in
immune disorder of after spleenectomy.

Administration and storage

In UIP, pentavalent vaccine comes in a liquid form in a vial which contains 10

doses. Each dose is 0.5 ml to be given by intra muscular injection in
anterolateral aspect of the mid-thigh using AD syringes. Discard injection waste
as per guideline for immunization waste management. Pentavalent vaccine is a
freeze sensitive vaccine, and should be stored and transported at +2 to +8 degree
celsius in ice lined refrigerators and vaccine carriers with conditioned ice packs.

Dosage

Three doses are given. The first dose is given as pentavalent vaccine only after a
child is 6 weeks old. The second and third doses are given at 10 and 14 weeks
of age respectively also in the form of pentavalent vaccines. There is no booster
dose recommended under UIP. The schedule for DPT, Hep B and Hib is the
same at 6, 10 and 14 weeks. Therefore, if these three vaccines are given
separately, a child gets three pricks at the same time. Giving a pentavalent
vaccine will reduce the number of pricks.

Adverse reaction

Pentavalent vaccine has not been associated with any serious side effects.
However, redness, swelling, and pain may occur at the limb site where the
injection was given. These symptoms usually appear the day after the injection
has been given and last from one to three days. Less commonly, children may
develop fever for a short time after immunization.

Contraindications

Age-a child below 6 weeks of age should not be given Pentavalent Vaccine.
Vaccination history-a child whose vaccination schedule has been initiated with
52
DPT/hepatitis B vaccine will continue to receive subsequent doses of
DPT/hepatitis B and not Pentavalent Vaccine Severe allergic reactions-although
serious side effects have not been reported, a child who has had a severe
reaction to Pentavalent Vaccine earlier should not be given another dose.
Children with moderate or severe acute illness should not be administered
Pentavalent Vaccine until their condition improves. Minor illnesses, however,
such as upper respiratory infections (URIs) are not a contraindication to
vaccination.

Do’s and Don’ts in vaccination

 Do not massage the area after injection

 Give cold compression at the injection site
 Give oral paracetamol to reduce pain
 Watch for redness or swelling at the injection site
3. Inactivated Polio Vaccine

The first generation IPV was made by formalin inactivation of polioviruses

grown on monolayer cell cultures. The three types were prepared and blended to
make the vaccine. A massive field trial was conducted in the USA and a few
other countries and it was found to be quite efficacious and completely safe.

Oral Polio Vaccine

By laboratory manipulations of wild polioviruses, virus ‘strains’ with markedly

reduced neurovirulence in monkeys were selected by Albert Sabin to make
OPV. The vaccine viruses are popularly called Sabin strains.

Immunogenicity of IPV and OPV

Immunogenicity is the ability to induce immune response(s) in the host. In the

case of vaccines, it must be viewed in quantitative terms-both the proportion of
vaccinated subjects responding adequately and also the height of immune
53
response. In polio, systemic humoral immunity is the aim of vaccination; it
protects the person against the disease. Therefore, immunogenicity is measured
as the frequency of antibody response among vaccinated children who were
previously seronegative, usually denoted as seroconversion rate.

Immunogenicity of IPV

Immunogenicity of IPV is dampened by the presence of maternal antibody in

the very young infant, especially up to the age of 8 weeks or two months.5 For
consistent results, 14 weeks of age is better than 8 weeks for the first dose.

Purpose of giving IPV

The oral polio vaccine is a safe and effective tool for immunizing children
against polio. The efficacy of IPV in preventing poliomyelitis is excellent. IPV
administration has the advantage of not causing VAPP.( vaccine associated
paralytic polio).

Administration

IPV is subcutaneously and combination vaccines given intramuscularly. A The

regular schedule is to give 3 doses at 6,10 and 14 weeks.

OPV will give at birth. The OPV is given by mouth, as stipulated by

manufacturers. For convenience, two drops from the dispenser constitutes one
dose.

Storage

IPV: They should be stored under refrigeration (2-8 degree Celsius). However,
these products are quite stable even at higher temperatures at which most
protein antigens are preserved. Those products containing whole-cell pertussis
antigens or aluminium adjuvant should not be frozen.

54
OPV: The OPV is supplied in preservative-free liquid preparations. It is most
stable below freezing temperatures, but it is also quite stable under refrigeration.
All enteroviruses are relatively resistant to moderately higher temperatures, but
they gradually get inactivated over time.

Adverse reactions

The IPV causes injection-related minor pain and discomfort but hardly any
systemic problems such as fever or malaise. Children given OPV shed virus in
their feces for several days to a few weeks. The shed virus exhibits increasing
frequency of genetic reversion towards neurovirulence. The individuals with B
cell deficiency states, who have developed chronic infection with vaccine
viruses, and have continued to shed them in their feces.

Contraindications

If a child develops anaphylaxis following a dose of IPV, further doses are

contraindicated. The OPV is contraindicated in children with established or
suspected B cell-related immunodeficiency. Indeed, if a child is known to have
B cell immunodeficiency, no member of that family should be given OPV,
instead only IPV should be given. Similarly, after bone marrow transplantation,
only IPV should be given. Symptomatic children should not be given OPV.

Do’s and Dont’s in vaccination

 Pain will be present so oral analgesic should be given if necessary

 Watch for any anaphylactic reactions.
 Inform doctors regarding the allergic reaction occurred at the first
vaccination.
4. MEASLES RUBELLA (MR Vaccine)

In India, the triple combination vaccine (MMR) manufactured but now it is only
double combination of MR vaccine.
55
1. Measles vaccine

Measles vaccine is a live attenuated vaccine. Maternal immunity may interfere

with the immune response to the vaccine during infancy. Administration of the
vaccine at 9 months in endemic countries like India balances the need of early
protection with the ability to ensure seroconversion. Adequate titers of antibody
are generated in 85-90% at 9 months age. In case of an outbreak, vaccine
administration as early as 6 months of age may be carried out, with a repeat
dose at12-15 months as part of measles or MR vaccine.

2. Rubella vaccine
The use of rubella or MR vaccine in children without ensuring optimal
immunization coverage may result in an epidemiological shift of disease with
more clinical cases in adulthood and a paradoxical increase in congenital rubella
syndrome. Hence, the vaccine should be introduced in the National Program
only after ensuring that the routine immunization coverage is at least 80%.

Dosage and route of administration

The vaccine is administered in a 0.5ml dose. The recommended route of

administration is subcutaneous injection administered in the upper arm or antero
lateral aspect of thigh.

Storage

Measles vaccine is extremely stable between -70°C (-94°F) and -20°C (-4’F).
The reconstituted vaccine should be stored at -+2° to +8°C and used within four
hours. The reconstituted vaccine loses 50% of its potency after one hour at 20-
25°C and almost all potency after 1 hour at 37°c.

56
Adverse Effects

Fever of 39.4° C or higher (≥103° F) occurs in approximately 5% to 15 % of

vaccines between the 7th and 12th day after vaccination and lasts approximately I
to 2 days. Rash occurs in approximately 5% of recipients, beginning 7 to 10
days after vaccination and lasting for 1 to 3 days. The frequency of fever, rash,
and other side effects after second doses of measles-containing vaccines is
lower than after the first. Measles vaccine is associated with a mild decrease in
platelet counts within a few days after the vaccine is given, and rare cases of
idiopathic thrombocytopenic purpura (ITP) have been associated with measles-
containing vaccines. Immediate hypersensitivity reactions, including hives and
anaphylaxis.

Contraindications

Persons with history of anaphylactic reactions to neomycin should not receive

the vaccine.

Do’s and Dont’s in vaccination

 The vaccine should be used within 4 hour after reconstitution

 Watch for fever and give oral paracetamol syrup to the child
 Transient macular rash may occur, so keep observe the child after
vaccination
 Do not give vaccine if child is severely immunocompromised.
 Give vaccine only after 9 months because maternal antibodies interfere
with response to the vaccine if give earlier
5. PNEUMOCOCCAI VACCINE

S. pneumoniaeis responsible forl5-S0% of all episodes of community acquired

pneumonia, 30-50% of all cases of acute otitis media and 50% of deaths due to
pneumonia every Year. Among 90 known serotypes of S. pneumonia, 20

57
serotypes are responsible for 80% of invasive pneumococcal disease in all ages,
while only 13 serotypes account for 75% of disease burden in young children.

Purposes

Currently available polyvalent pneumococcal vaccine can protect children from

infection caused by streptococcus pneumonia resulting pneumonia, meningitis,
otitis media, bacteremia, etc. The protection efficacy is about 60 percent.

The vaccines are not immunogenic in children below 2 years of age. It is

indicated in Children above 2 years of age and having nephritic syndrome,
chronic renal failure, immunosuppressive conditions, malignancy, HIV
infection, spleenectomy, etc. The vaccine is given intramuscular or
subcutaneously with 0.5 ml amount. Revaccination is recommended for
children less than 10 years of age and are at high risk of severe pneumococcal
infection. It is given after 3 to 5 years of primary immunization.

The adverse reactions may found as anaphylaxis, local painful swelling, fever,
GB syndrome, etc.

Contraindications is child had anaphylaxis after previous dose.

6. MENINGOCOCCAL VACCINE
Neisseria meningitis is the major cause of bacterial meningitis accounting for
30-40% of cases in children below 15 Yr. Endemic cases and severe
meningococcal disease are primarily seen in children and adolescents; attack
rates are highest in infants between 3 and 12 months of age. Even with
treatment, case fatality rates are high . The infection is usually due to
serogroups A, B, C Yand W135; serogroup A (and sometimes C) may cause
epidemics. In India endemic cases are chiefly due to serogroup B. Infection
results in serogroup specific immunity. The meningococcal vaccine is indicated
in close contacts of patients with meningococcal disease (as an adjunct to

58
chemoprophylaxis), certain high-risk groups (complement deficiency, sickle
cell anemia, asplenia, before splenectomy) etc.

The vaccine is administered deep subcutaneously in single dose of 0.5 ml, in

children older than two years of age. When first dose is given after 4 years of
age, than next dose should be administered only after another 5 years.

The vaccine may have some adverse reactions like local tenderness, edema and
fever.

7. JAPANESE ENCEPHALITIS (JE) VACCINES

Japanese encephalitis is an important viral disease causing fatal condition in

children. Vaccination against JE is significant preventive measure as the
specific drugs are not available for treatment. At present three of JE vaccines
are available, i.e. mouse brain derived and inactivated viral vaccine, cell culture
derived inactivated vaccine and live attenuated vaccine.

The mouse brain derived JE vaccine is available internationally and stable at 4

°C for at least one year. The vaccine is administered in 2 doses subcutaneously,
with 0.5 ml amount to the children of 1 to 3 years age and with 1.0 ml for above
3 years age, at interval of 1-2 weeks. The 3rd dose can be given after 6 months
and booster dose every 3 to 4 years. Protective efficacy is about 90 to 95
percent. It is indicated in epidemics and endemics of JE. Contraindicated in high
fever, diabetes mellitus, liver and heart disease and immunodeficiency states.

8. ROTAVIRUS VACCINE

The two rotavirus vaccines that are available are Rotarix (GlaxoSmithKline)
and is a live, attenuated vaccine containing a single G1P[81 human rotavirus
strain, RotaTeq is a live, attenuated vaccine containing 5 human bovine
reassortant strains-G1P7[5], G2P7[8], G3P7[5], G4P7[5], and G6PlA(8}. Both
vaccines are administered orally to infants starting at a minimum age of 6

59
weeks, with a minimum 1 weeks interval between doses (2 doses for Rotarix, 3
doses for RotaTeq).

STORAGE AND MAINTENANCE OF VACCINE

All vaccines are sensitive biological substances and will lose potency if it is
exposed to improper temperature during its transport and storage. In order to
maintain their potency, all vaccines must be continuously stored at appropriate
temperature range from the time they are manufactured until the moment of
their use. Contrary to the common belief that exposure of vaccine to higher
temperature only can be damaged, freezing of vaccine also can cause
degradation and consequently total or partial loss of potency. Once the potency
of vaccine is lost, it cannot be regained or restored.

An effective logistics system and a well maintained cold chain are essential for
safe and effective immunization service delivery. Improperly functioning cold
chain can lead to wasted vaccines, missed opportunities to immunize due to lack
of vaccines, and children receiving vaccines that do not protect them as
intended or that actually make them sick.

COLD CHAIN

The ‘cold-chain’ is the system of transporting and storing vaccines within

recommended temperature range from the place of manufacture to the point of
administration. It has three main components:

1. Vaccine transport and storage equipment

2. Trained personnel
3. Efficient management procedures

STORAGE OF VACCINES

Heat and Freeze Sensitivity of Vaccines

60
All vaccines are sensitive to heat to some extents but some are more sensitive
than others. All freeze-dried vaccines become much more sensitive to heat after
they have been reconstituted.

Some vaccines are also sensitive to excessive cold; and if the vaccine is frozen,
it will become useless.

All the vaccines that have ‘t’ in it (i.e. TI. DT, dT, DTP,Vi typhoid), hepatitis A,
hepatitis B, Hib vaccines are freeze, sensitive vaccines and care should be taken
that they do not get frozen while transport and storage. Newer costly vaccines
such as conjugate pneumococcal vaccines and rotavirus vaccines, are also
freeze-sensitive vaccines and should be stored between 2 and 8°C.

Sensitivity to Light

Some of the vaccines are also very sensitive to light. These vaccines when
exposed to ultraviolet (UV) light will also cause loss of potency, so they must
always be protected against sunlight or fluorescent light (neon). BCG, measles,
MR, MMR, rubella vaccines are sensitive to light and so these vaccines are
supplied in dark brown glass vials, which protect them against light damage.

Recommended Storage Temperature

At the higher level of cold chain that is national and regional OPV must be kept
frozen between -15 and-25oC. Freeze-dried vaccines (BCG, measles, MMR)
may also be kept frozen at-15 to-25°C. At other level of cold chain, these
vaccines should be stored at 2-8°C. If a vaccine is damaged by heat and loses
some of its potency, this loss can never be restored and this damage is
cumulative with fresh damage occurring each time the temperature fluctuates
outside the recommended vaccine storage temperature range.

61
VII. NUTRITION AND NUTRITIONAL REQUIREMENTS
The science of human nutrition is mainly concerned with defining the
nutritional requirements for the promotion, protection and maintenance of
health in all group of the population. Such knowledge is necessary in order to
assess the nutritional adequacy of diets for growth of infants, children and
adolescents, and for maintenance of health in adults of both sexes and during
pregnancy and lactation in women.
Recommended dietary allowance (RDA): The average daily dietary nutrient
intake level sufficient to meet the nutrient requirement of nearly all (97-98 per
cent) healthy individuals in a particular life stage and gender group.
Adequate intake: A recommended average daily intake by a group apparently
healthy people, that are assumed to be adequate – used when an RDA cannot be
determined. In the Indian context, this is referred to as “acceptable intake”.
Tolerable upper intake level (UL): The highest average daily nutrient intake
level that is likely to pose no risk of adverse health effects for almost all
individuals in the general population. As intake increases above the UL, the
potential risk of adverse effect increases.
Estimated average requirement (EAR): The average daily nutrient intake
level estimated to meet the requirement of half of the healthy individuals in a
particular life stage and gender group.
Reference body weight: Age, gender and body weight largely determine the
nutritional requirement of an individual. Body weights and heights of children
reflect their state of health, nutrition and growth rate, while weight and heights
of adults represent what can be attained by an individual with normal growth.
Anthropometric measurements of infants and children of wellto-do families
having access to good health care and no nutritional constraints are usually
treated as reference values. The purpose of recommending nutrient requirements
is to help attaining these anthropometric reference standards.

62
WHO standard weights and heights of infants and pre-school children
World Health Organization has recently published multicentre growth reference
standards for 0-60 month boys and girls, based on studies carried out among
predominantly exclusively breast-fed children in six countries viz., USA, Brazil,
Ghana, Norway, Oman and India. The median weights of infants and pre-school
children (1-3 years) can be taken as reference values for Indian children.
Infants
The average of birth weight and body weight at 6 months is used for computing
the reference body weight for infants 0-6 months of age. For 6-12 months, an
average of body weight at 6 months and at 12 months is taken for computation.
Children
For children 1-3 years of age, an average of body weight at 18 months, 30
months, 42 months of WHO median weight is taken. The reference body weight
for children of 4-6 years are obtained by averaging the body weight of 4+, 5+
and 6+ years. Similarly for other age groups also the reference body weights
were obtained from the 95th centile value of body weights of rural India.
1. ENERGY
Energy is a prime requisite for body function and growth. When a child’s intake
of food falls below a standard reference, growth slows, and if low levels of
intake persist, adult stature will be reduced. Similarly, if adults fail to meet their
food requirements they lose weight. This may lead to reduced ability to work, to
resist infection, and weakened will to enjoy the normal satisfaction of life. This
underlines the need for an adequate intake of food which is the source of all
energy.
a. Measurement of energy
The energy value of foods has long been expressed in terms of the kilo-calorie
(kcal). The kilo-calorie is generally expressed as “Calorie”-written with a
capital “C”. This has been replaced by the joule expressed as J, which has been
accepted internationally.

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Joule, a physical unit of energy, is defined as the energy required to move 1 kg
of mass by 1 metre by a force of 1 Newton acting on it (One Newton is the force
needed to accelerate one kg mass by 1 metre per sec2).
Kilo calories (kcal) is defined as the heat required to raise the temperature of
one kg of water by 10C from 14.5°C to 15.S-c. The unit kcal is used.
The relationship between the two units of energy is as follows:
1 kcal = 4.184 KJ (Kilo Joule)
1 kcal = 0 .239 kcal
1000 kcal = 4184 KJ = 4.18 MJ (Mega Joule)
1 MJ = 239 kcal
b. Energy requirements
The energy requirement of an individual is defined as that level of energy intake
from food that balances energy expenditure, when the individual has a body size
and composition and level of physical activity, consistent with long-term good
health, also allowing for maintenance of economically essential and socially
desirable activity. In children and pregnant and lactating women, it includes the
energy needs associated with the deposition of tissues or secretion of milk at
rates consistent with good health.
c. Factors affecting energy requirements
Energy requirements vary from one person to another depending upon inter-
related variables acting in a complex way, such as age, sex, working condition,
body composition, physical activity, physiological state etc. All these factors
lead to differences in food intake.
1. Vulnerable groups
(a) Pregnant and lactating mothers: The energy requirements of women
are increased by pregnancy (+ 35 kcal daily throughout pregnancy) and
lactation (+600 kcal daily during the first 6 months, and + 520 kcals daily
during the next 6 months) over and above their normal requirements. This is to

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provide for the extra energy needs associated with the deposition of tissues or
the secretion of milk at rates consistent with good health.
(b) Children: Because of their rapid growth rate, Young children require
proportionately more energy for each kilogram of body weight than adults.
Children above the age of 13 years need as much energy as adults. This is
because they show a good deal of physical activity, almost equal to hard work
by adults. This is also the age when puberty sets in and there is a spurt in growth
and an increase in metabolic rate. This fact should be borne in mind when
planning dietaries for children.
d. Source of energy
The main source of energy in Indian diets, which are predominantly plant food
based, are carbohydrate, fat, protein and dietary fibre. They supply energy at the
following rates:
Protein - 4 kcal/ g
Fat - 9 kcal/g
Carbohydrate - 4 kcal/g
Dietary fibre- 2 kcal/g
Dietary fibre forms an indigestible and important component of plant food and
was never earlier considered as source of energy. These dietary fibres (soluble
and insoluble) undergo fermentation in the colon and yield short chain fatty
acids, such as butyric, propionic and acetic acids which are utilized as a source
of energy by the colon cells and by the liver. Hence they are known to yield
energy from fermentable fibre and no energy from non-fermentable fibre. In
general, energy conversion factor for fibre is taken as 2.0 kcal/g. Hitherto,
dietary fibre was not determined directly as a source of energy and there is a
need to recalculate energy yield of various foods on the basis of their revised
content of carbohydrates, proteins, fat and dietary fibre.

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2.PROTEIN
Protein requirements vary from individual to individual. Apart from age, sex
and other physiological variables, factors like infection, worm infestation,
emotional disturbances and stress situations can affect a person’s protein
requirement.
a. Assessment of protein
i.Protein Quality
The quality of a protein is assessed by comparison to the “reference protein”
which is usually egg protein. Two methods
(i) Amino acid score: It is a measure of the concentration of each essential
amino acid in the test protein expressed as a percentage of that amino acid in the
reference protein.
Mg of amino acid per g of test protein
Amino acid score = 100
Mg of the same amino acid
per g of reference protein.
The amino acid (or chemical) score is somewhere between 50 and 60 for
starches, and 70 and 80 for animal foods.
(ii) Net protein utilization (NPU): It is a product of digestibility coefficient
and biological value divided by 100. The NPU gives a more complete
expression of protein quality than the amino acid score. It is a biological method
that requires special laboratory facilities.
Nitrogen retained by the body
NPU = 100
Nitrogen intake
In calculating protein quality, 1 gram of protein is assumed to be equivalent to
6.25 g of N. The protein requirement varies with the NPU of dietary protein. If
the NPU is low, the protein requirement is high and vice versa. The NPU of the
protein of Indian diets varies between 50 and 80.

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ii) Protein Quantity
The protein content of many Indian foods has been determined and published in
food composition tables. One way of evaluating foods as source of protein is to
determine what per cent of their energy value is supplied by their protein
content. This is known as Protein-Energy Ratio (PE ratio or percentage).

Energy from protein

PE per cent = 100
Total energy in diet
6. Dietary intakes
It is customary to express requirement in terms of grams per kg of body weight.
This principle applies to all age groups, although absolute additions in units of
grams of protein per day are made for pregnancy and lactation.
The protein requirements of women are increased during pregnancy. For 10 kg
gestational weight gain the requirement increases by 1, 7 and 23 g/day in 1st, 2nd
and 3rd trimesters respectively; and during lactation by about 13 g per day
(during 0 to 6 months), over and above their normal requirements. Young
children (0 to 6 years) require proportionately more protein for each kilogram of
body weight than adults. They are more vulnerable to malnutrition. The ICMR
Expert Group has not made any recommendations for the elderly. It seems
reasonable to assume that the requirement of the aged are not less than for
young adults, because it is an accepted fact that protein utilization is less
efficient in the elderly.
All estimates of protein requirement are valid only when the energy
requirements are fully met. If the total energy intake is inadequate some dietary
protein will be diverted to provide energy. It is now accepted that there are no
body, protein stores which can be filled up by a high protein intake.

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Amino acid requirements
The protein intake must also satisfy the need for essential amino acids. The
2007 WHO Expert Committee Report on Energy and Protein Requirements
gives current estimates of amino acid requirements (in mg/kg per day) for
adults. New tissues cannot be formed unless all the essential amino acids are
present in the diet. The requirement of EAA decreases sharply as one advances
in age. The quality of the diet is far more critical for the infant than for the
adult.
3.FAT
The daily requirement of fat is not known with certainty. During infancy, fats
contribute to a little over 50 per cent of the total energy intake. This scales down
to about 20 per cent in adulthood. The ICMR Expert Group (2010) has
recommended an intake of 20 per cent of the total energy intake as fat, of which
at least 50 per cent of fat intake should consist of vegetable oils rich in essential
fatty acids. The requirement of essential fatty acids ranges from 3 per cent
energy intake to 5.7 per cent of energy intake in young children.
4. CARBOHYDRATE
The recommended intake of carbohydrate in balanced diets is placed so as to
contribute between 50 to 80 per cent of total energy intake. Most Indian diets
contain amounts more than this, providing as much as 90 per cent of total
energy in take in some cases, which makes the diet imbalanced. This needs to
be corrected through nutrition education.
5.OTHER RECOMMENDED INTAKE
a. Fat soluble vitamins
The daily requirement of vitamins A is 2800 micro gram. The recommended
dietary allowance of vitamin E is placed at 10 mg of alpha tocopherol
equivalents for adult males and 8 mg for adult females.

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b.Water soluble vitamins
The requirements of thiamine, riboflavin and niacin are closely related to energy
intake and utilization, and are stated in terms of 1000 kcal intake of energy.
Thiamine ….. 0.5 mg/1000 kcal
Riboflavin….. 0.6 mg/1000 kcal
Niacin ….. 6.0 mg/1000 kcal

c.Minerals
All nutritional requirements are interrelated. For example, there is a close
interrelationship between the energy and protein requirements, between
requirements for phosphorus, calcium and vitamin D, between fats and
vitamins, and between carbohydrates and vitamins. It has been said that food is
not only a collection of nutrients open to statistical or dietary study, but also
simultaneously a system of communication, a protocol for customs, situations
and behaviour.
VIII. BREAST FEEDING

The nature has designed the provision that infants be feed upon their
mother’s milk. They find their food and mother at the same time. It is a
complete nourishment for them both for their body and soul. Breastfeeding is
the most effective way to provide a baby with a caring environment and
complete food. It meets the nutritional well as emotional and psychological
needs of the infant. Breastfeeding is now an endangered practice around the
world, in both rich and poor countries. There is unanimous agreement on the
need for, and the route to, global support for breastfeeding through various
approaches and programs. Baby Friendly Hospital Initiative is one of the
important interventions towards that goal.

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a.Advantages of Breastfeeding

Breastfeeding is safest, cheapest and best protective food for infants. Superiority
of human milk is due to its superior nutritive and protective value. It is perfect
food for infants and provides total nutrient requirements for the first six months
of life. When combined with appropriate weaning foods, it is an invaluable
source of nourishment until past the second birth day. It prevents malnutrition
and allow the child to develop fully.

1. Nutritive Value: Breast milk contains all the nutrients in the right
proportion which are needed for optimum growth and development of the
baby up to 6 months. It is essential for brain growth of the infant because
it has high percentage of lactose and galactose which are important
components of galactocerebroside. It facilitates absorption of calcium
which helps in bony growth. It contains amino acids like taurine and
cysteine which important as neurotransmitters. Breast milk fats are
polyunsaturated fatty acids which are necessary for the myelination of the
nervous system. It has vitamins, minerals, electrolytes and water in the
right proportion for the infant which are necessary for the maturation of
the intestinal tract. It provides 66 calories per 100 ml and contains 1.2 g
protein, 3.8 g fat, 7 g lactose and vitamin A 170 to 670 IU, vitamin ‘C’ 2
to 6 mg, vitamin D 2.2 IU, calcium 35 mg, phosphorus 15 mg in 100 ml,
The total amount of milk secretion per day is about 600 to 700 ml, which
is sufficient for the baby. Its composition is ideal for an infant. It provides
specific nutrition for preterm baby in preterm delivery.
2. Digestibility: Breast milk is easily digestable. The protein of breast milk
mostly lactoalbumin and lactoglobulin which form a soft curds that is
easy to digest. The enzyme lipase in the breast milk helps in the digestion
of fats and provides free fatty acids.
3. Protective Value: Breast milk contains IgA, IgM, macrophages,
lymphocytes, bifidus factors, unsaturated lactoferrin, Iysozyme, complement
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and interferon. Thus breastfed body less likely to develop infections especially
gastrointestinal and respiratory tract infections, e.g. diarrhea and ARI. It also
provides protection against malaria and various viral and bacterial infections
like skin infections, septicemia, etc.
4. Psychological Benefits: Breastfeeding promotes close physical and
emotional bondage with the mother by frequent skin to skin contact, attention
and interaction. It stimulates psychomotor and social development. It leads to
better parent child adjustment, fewer behavioral disorders in children and less
risk of child abuse and neglect. Breastfeeding promotes development of higher
intelligence and feeling of security in infant.
5. Maternal Benefits: Breastfeeding reduces the chance of postpartum
hemorrhage and helps in better uterine involution. Lactational amenorrhea
promotes in recovery of iron stores. It can protect from pregnancy for first 6
months if exclusive breastfeeding is carried out. Breastfeeding improves
metabolic efficiency and satisfaction with sense of fulfillment of the mother. It
reduces the risk of breast and ovarian cancer of the mother. It improves
slimming of the mother by consuming extra fat which accumulated during
pregnancy. It is more convenient and time saving for the mother. It is more
convenient and time saving for the mother. Mother can provide fresh, pure,
readymade, clean uncontaminated milk to her baby at right temperature without
any preparations. Mother feels comfortable to feed the baby especially at night.
6. Family and Community Benefits: Breastfeeding is economical in terms
of saving of money, time and energy. Family has to spend less on milk, health
care and illness. Community expenditure on health care and contraception are
reduced. It is economic for the families, hospitals, communities and for
countries.

b.Initiation of Breast feeding

Breastfeeding should be initiated within first half an hour to one hour of birth or
as soon as possible. It should also be initiated within one hour even after
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cesarean section delivery, if the mother and baby, both are having no problem.
Early suckling provides warmth, security and colostrum, the baby s first
immunization. Although little in amount, the first milk, colostrums, is most
suitable and contains a high concentration of protein and other nutrients, the
baby needs. It is rich in anti-infective factors and protects the baby from
respiratory infections and diarrheal diseases.

Mothers should be demonstrated about the techniques of breast feedings.

Rooming-in or bedding-in should be done with infant and mother as soon as
possible to prevent separation. Mother should be advised for exclusive
breastfeeding up to 6 months and as demand feeding.

No food or drink other than breast milk should be given to neonates. No water,
glucose water, animal milk, gripe water, indigenous medicines, vitamins and
minerals drops or syrup should be given. No bottle and pacifier are allowed.

In case of preterm babies or sick babies, being in special care unit, they should
be fed with expressed breast milk. Nursing staff is responsible to ensure that
nothing except breast milk is given. Mother should be instructed to assess the
indicators of adequacy of breastfeeding and importance of increasing her own
dietary intake with extra 550 cal and to drink fluids in response to her thirst.
Rest and relaxation of mother are important for recovery from delivery and
successful lactation in postnatal period.

c.Compositions of breast milk

 Colostrum

Colostrum is the golden-yellow milk secreted during the first three days after
delivery. It is yellow and thick and contains more antibodies and white blood
cells. Though secreted in small quantities, it is hither protein content and is
most suited to serve the nutritional and immunological needs of the baby. It is
loaded with protective secretory immunoglobulins and virtually works like a

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“first vaccine shot” for the baby by blocking the entry of pathogenic bacteria
through the gut. It should never be discarded and is indeed the ideal first meal
of the baby.

 Transitional milk

It follows the colostrum and secretes during first two weeks of postnatal period.
It has increased fat and sugar content and decreased protein and
immunoglobulin content

 Mature milk

It is secreted usually from 10 to 12 days after delivery. It is watery but contains

all nutrients for optimal growth of the baby

 Hind milk

It is secreted towards the end of regular breastfeeding and contains more fat and
energy. The mother should feed the baby allowing one breast to empty to
provide both fore milk and hind milk, before offering other breast. For optimum
growth, the baby needs both fore as well as the hind milk. The baby should
therefore be allowed to empty one breast completely before being put on to the
other breast

 Fore milk

Fore milk secreted at the starting of the regular breast feeding. it is more watery
to satisfy the baby’s thirst and contains more proteins, sugar, vitamins and
minerals

 Preterm milk

The milk of a mother who delivers prematurely contains more calories, higher
concentration of fat, protein and sodium which are needed by her preterm baby.
The concentrations of lactose, calcium and phosphorus are lower as compared
to milk produced by mothers of term infants. During next 2-3 weeks, the
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composition of milk gradually changes and assumes composition akin to mature
milk.

d.Establishment of Lactation

The motivation and preparation for breast feeding should begin during
antenatal period. Awareness, willingness, keenness and confidence on the part
of mother are crucial for successful establishment of lactation. Early bonding
soon after delivery promotes breast feeding. Healthy infant should be roomed-
in with the mother and should never separate from the mother by keeping him in
the nursery. Early breast feeding in all babies. irrespective of the mode of
delivery, and avoidance of prelacteal and prolacteal feeds are essential to
establish successful breast feeding.
Manual breast milk expression

Manually expressing breast milk can enhance milk production and ensure
an adequate supply. It’s especially helpful for mothers who have problems with
engorgement or those who must be away from their infants for several hours.
(A mother who works outside the home or is away on a regular basis may find
and electric pump quicker and more efficient.)

To help the mother manually express breast milk, follow these steps:

 Make sure that a clean collection container is available and that you and
the patient have washed your hands.
 Explain the procedure to the patient, have her sit in a comfortable
position, and provide privacy.
 Tell her to place her dominant hand on one breast with the thumb
positioned on the top and the fingers below and at the outer limit of the areola.
 Instruct her to press her thumb and fingers inward toward her chest while
holding the collection container with her opposite hand directly under the
nipple.
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 Tell the patient to move her thumb and fingers forward, using a gentle
pressure in a milking type motion. Caution her not to use too much pressure
because this can injury to breast tissue. Milk should flow out of the nipple and
into the collection container.
 Encourage the patient to move her thumb and fingers around the breast,
using the same motion, to ensure complete emptying.
 Advice the patient to cover the container and place the milk in the
refrigerator if it will be used within 24 hours; if not, she should freeze it.
e.Contraindications of Breast feeding
The true contraindications of breastfeeding are galactosemia and
phenylketonuria. Maternal conditions which can be considered as ‘REAL’
contraindications are Radiotherapy, Ergot therapy, Antimetabolites therapy and
Lithium therapy. Maternal illness should not result in interruption of
breastfeeding. Expressed breast milk (EBM) can be given to the baby, whenever
needed, from the mother or mother’s substitute.
IX. BABY FRIENDLY HOSPITAL INITIATIVE

Since 1993 WHO’s efforts to improve infant and young child nutrition have
focused on promoting breast feeding. It has been calculated that breast feeding
could prevent deaths of at least one million children a year. A new “baby-
friendly hospital initiative (BFHI), created and promoted by WHO and
UNICEF, has proved highly successful in encouraging proper infant feeding
practices, starting at birth. BFHI is supported by the major professional medical
and nursing bodies in India. The global BFHI has listed ten steps which the
hospital must fulfil. This includes: {1) helping the mother initiate breast-feeding
within the first hour of birth in normal delivery and 4 hours following caesarean
section; (2) encourage breast-feeding on demand; (3) allow mothers and infants
to remain together 24 hours a day, except for medical reasons; (4) give newborn
infants no food or drink, other than breast-milk unless medically indicated;
exclusive breast-feeding should be promoted till 4-6 months of age; (5) no
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advertisement, promotional material or free products for infant feeding should
be allowed in the facility, (6) show mother how to breast-feed, and how to
maintain lactation even if she is separated from her infant; (7) give no artificial
teats or pacifiers (also called dummies or soothers) to breast feeding infants; (8)
encourage mothers to assist each other and to develop breast feeding support
groups; (9) nursing staff should be available to counsel families and mother in
support of exclusive breast feeding. The ‘’Baby friendly” hospitals in India are
also expected to adopt and practice guidelines on other interventions critical for
child survival including antenatal care, clean delivery practices, essential new-
born care, immunization and ORT.

In order to encourage and promote exclusive breast feeding to enhance child

survival, the Baby Friendly Hospital Initiative (BFHI) was launched jointly by
WHO and UNICEF in March, 1992 Have a written breast feeding policy that
is routinely communicated to all health staff.

 Train health care staff in skills necessary to implement this policy.

 Inform all pregnant women about the benefits and management of
breast feeding.
 Help mothers to initiate breast feeding within half-hour of birth.
 Show mothers how to breast feed and how to maintain lactation, even
if they are separated from their infants.
 Give newborn infants no food or drink other than breast milk, unless
medically indicated.
 Practice rooming-in and allow mothers and infants to remain
together round-the-clock.
 Encourage breast feeding on demand.
 Give no artificial feeds or pacifiers (also called dummies and
soothers) to breast feeding babies.

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 Foster the establishment of breast feeding support groups and refer
mothers to them on discharge from the hospital or clinic.
X. HEALTH EDUCATION
Health education is a term commonly used and referred to by health
professionals.

Definitions
Health education is indispensable in achieving individual and community
health. It can help to increase knowledge and to reinforce desired behavior
patterns. But there is no single acceptable definition of health education. A
variety of definitions exist. Concepts of health education as a process or an
activity for inducing behavioural changes are emphasized in the following
definitions:
1. Health education is the translation of what is known about health, into
desirable individual and community behavior patterns by means of an
educational process
2. The definition adopted by John M Last is “The process by which
individuals and groups of people learn to behave in a manner conducive to the
promotion, maintenance or restoration of health”
3. Any combination of learning opportunities and teaching activities
designed to facilitate voluntary adaptations of behavior that are conducive to
health
4. The definition adopted by the National Conference on Preventive
Medicine in USA is “Health education is a process that informs, motivates and
helps people to adopt and maintain healthy practices and lifestyles, advocates
environmental changes as needed to facilitate this goal and conducts
professional training and research to the same end”
5. Health education is the part of health care that is concerned with
promoting healthy behavior
Alma Ata Declaration
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The Declaration of Alma – Ata (1978) by emphasizing the need for “individual
and community participation” gave a new meaning and direction to the practice
of health education. The dynamic definition of health education is now as
follows:
“A process aimed at encouraging people to want to be healthy, to know how to
stay healthy, to do what they can individually and collectively to maintain
health, and to seek help when needed”
The Alma – Ata Declaration has revolutionized the concepts and aims of health
education
The modern concept of health education emphasizes on health behavior and
related actions of people.
Health education and behavior
The behaviours to be adopted or modified may be that of individuals, groups
(such as families, health professionals, organizations or institutions) or entire
community.
Strategies designed to influence the behavior of individuals or groups will vary
greatly depending upon the specific disease (or health problem) concerned and
its distribution in the population as well as upon the characteristics and
acceptability of available methods preventing or controlling that disease (or
health problem).
Health education can help to increase knowledge and to reinforce desired
behavior patterns. It is clear that education is necessary, but education alone is
insufficient to achieve optimum health. The target population must have access
to proven preventive measures or procedures.
Changing concepts
Historically health education has been committed to disseminating information
and changing human behavior. Following the Alma – Ata Declaration adopted
in 1978, the emphasis has shifted from
-Prevention of disease to promotion of healthy lifestyles;

78
-The modification of individual behavior to modification of “social
environment” in which the individual lives
-community participation to community involvement
-promotion of individual and community “self reliance”.
Aims and objectives
The definition adopted by WHO in 1969 and the & Alma Ata Declaration
adopted in 1978 provide a useful basis for formulating the aims and objectives
of health education, which may be stated as below:
1. To encourage people to adopt and sustain health promoting lifestyle and
practices:
2. To promote the proper use of health services available to time
3. To arouse interest, provide new knowledge, improve skills and change
attitudes in making rational decisions to solve their own problems; and
4. To stimulate individual and community self-reliance and participation to
achieve health development through individual and community involvement at
every step from identifying problems to solving them.
The educational objectives are aimed at the group to be taught in the
educational programme. The objectives flow from the health needs which have
been discovered. They should be carefully unambiguously defined in terms of
knowledge to be acquired, behavior to be acquired or actions to be mastered.
They must be pertinent if the programme is to be appropriate and successful.
The focus of health education is on people and on action. Its goal is to make
realistic improvements in the basic quality of life. Many health education
programmes hope, in some way, to influence behavior or attitudes. The
implication of these new concepts is that health education is an integral part of
the national health goals. The fact remains that effective health education has
the potential for saving many more lives than has any one research discovery in
the foreseeable future.

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Role of health care providers
It is clear that education is necessary, but education alone is not sufficient to
achieve optimum health. The role of health care providers in this regard
comprise to
a. Provide opportunities for people to learn how to identify and analyse
health and health related problems, and how to set their own targets and
priorities
b. Make health and health related information easily accessible to the
community
c. Indicate to the people alternative solutions for solving the health and
health-related problems they have identified
d. People must have access to proven preventive measures.
APPROACH TO HEALTH EDUCATION
There are 4 well-known approaches to health education :
1.Regulatory approach (Managed prevention)
Regulation in the context of health education may be defined as any
governmental intervention, direct or indirect, designed to alter human behavior.
Regulations may be promulgated by the State by a variety of administrative
agencies. Regulations may take many forms ranging from prohibition to
imprisonment.
The coercive or regulatory approach seeks change in health behavior and
improvement in health through a variety of external control or laws placed on
people, as for example, The Child Marriage Restraint Act in India and the use of
compulsory seat belts in the western countries. The legislative approach may
seem to be simplest and quickest way to improve health or bring about desired
changes in society, but there are also important failures of laws, e.g, prohibition
of alcohol.
The reasons for the failure of the coercive approach are not far to seek; in the
first place, the cause of disease (medical or social) cannot be eradicated by

80
legislation, at the most the government can make laws to prevent a person
spreading disease in his community, as for example vaccination in an
emergency. Secondly in areas involving personal choice (e.g., diet, exercise,
smoking) no government can pass legislation to force people to eat a balanced
diet or not to smoke. It amounts to taking away some of the rights of the
individual. The disastrous sterilization campaign of 1976 in India which led to
the Congress defeat in the 1977 elections is a case in point. The lesson learnt is
that it is difficult to enforce a law unless the majority of people are in favour of
it and if it does not interfere with the rights of the individual.
However, laws may be useful in times of emergency or in limited situations
such as control of an epidemic disease or management of fairs and festivals.
Even in cases where it is the duty of the government to make laws to prevent the
spread of disease (e.g,AIDS) it is difficult to enforce laws without a vast
administrative infrastructure and considerable expenditure. To a degree, the
people must be ready to accept a law. In short, the coercive approach runs
counter to the basic tenet of health education, that is, in health education, we do
not force people to change. In specific situations, legislation can be used to
reinforce the pressure to change collective behavior.
2. Service approach
This approach was tried by the Basic Health Services in 1960’s. It aimed at
providing all the health services needed by the people at their door steps on the
assumption that people would use them to improve their own health. This
approach proved a failure because it was not based on the felt-needs of the
people. For example, when water-seal latrines were provided by the
government, free of cost, many people in the rural areas did not make use of
them because it was not their habit to use latrines. The lesson is simple – the
people will not accept a programme or service, even if it is offered free of cost,
unless it is based on their felt-needs.

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 3. Health education approach
There are many problems (e.g,cessation of smoking, use of safe water supply,
fertility control) which can be solved only through health education. It is a
general belief in western democracies that people will be better off if they have
autonomy over their own lives, including health affairs on which an informed
person should be able to make decisions to protect his own health. These are the
higher goals of health education. However, if the necessary behavior changes
are to take place, people must be educated through planned learning experiences
what to do, and be informed, educated and encouraged to make their own
choice for a healthy life. This approach is consistent with democratic
philosophy which does not “order” the individual. The results are slow, but
enduring. The mass media and social organizations must be mobilized to help
introduce new attitudes and new habits without conflicting with the masses and
the collective reaction to particular change.
4. Primary health care approach
This is a radically new approach starting from the people with their full
participation and active involvement in the planning and delivery of health
services based on principals of primary health care, viz community involvement
and intersectoral coordination. The underlying objective is to help individuals to
become self-reliant in matters of health. This, in turn, can be done if the people
receive the necessary guidance from health care providers in identifying their
health problems and finding workable solutions. This approach is a fundamental
shift from the earlier approaches.
XI. NUTRITIONAL PROGRAMES IN THE COMMUNITY
The Government of India have initiated several large-scale at overcoming
specific deficiency diseases through various Ministries to combat malnutrition.
1. Vitamin A prophylaxis program
One of the components of the National Programme for Control of Blindness is
to administer a single massive dose of an oily preparation of vitamin A

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containing 200,000 lU orally to all pre-school children in the community every
6 months through peripheral health workers. This programme was launched by
the Ministry of Health and Family Welfare in 1970 on the basis of technology
developed at the National Institute of Nutrition at Hyderabad. An evaluation of
the programme has revealed a significant reduction in vitamin A deficiency in
children.
2. prophylaxis against nutritional anaemia
In view of its public health importance, a national programme for the prevention
of nutritional anaemia was launched by the Govt. of India during the fourth Five
Year Plan. The programme consists of distribution of iron and folic acid
(folifar) tablets to pregnant women and young children (0-12 years). Mother and
Child Health (MCH) Centres in urban areas, primary health centres in rural
areas and ICDS projects are engaged in the implementation of this programme.
The technology for the control of anaemia through iron fortification of common
salt has also been developed at the National Institute of Nutrition at Hyderabad.
3. Control of iodine deficiency disorders
The National Goitre Control Programme was launched by the Govt. of India in
1962 in the conventional goiter belt in the Himalayan region with the objective
of identification of goiter endemic areas to supply iodized salt in place of
common salt and to assess the impact of goiter control measures over a period
of time.
Surveys, however, indicated that the problem of goiter and iodine deficiency
disorders was more widespread than it was thought earlier, with nearly 145
million people estimated to be living in known goiter endemic areas of the
country. As a result, a major national programme – the IDD Control Programme
– was mounted in 1986 with the objective to replace the entire edible salt by
iodide salt, in a phased manner by 1992.

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4. Special nutrition programme
This programme was started in 1970 for the nutritional benefit of children
below 6 years of age, pregnant and nursing mothers and is in operation in urban
slums, tribal areas and backward rural areas. The supplementary food supplies
about 300 kcal and 10-12 grams of protein per child per day. The beneficiary
mothers receive daily 500 kcal and 25 grams of protein. This supplement is
provided to them for about 300 days in a year. This programme was originally
launched as a Central programme and was transferred to the State sector in the
fifth Five Year Plan as part of the Minimum Needs Programme. The main aim
of the Special nutrition Programme is to improve the nutritional status of the
target groups. This programme is gradually being merged into the !CDS
programme.
5. Balwadi nutrition programme
This programme was started in 1970 for the benefit of children in the age group
3-6 years in rural areas. It is under the overall charge of the Department of
Social Welfare. Four national level organizations including the Indian Council
of Child Welfare are given grants to implement the programme. Voluntary
organizations which receive the funds are actively involved in the day-to-day
management. The programme is implemented through Balwadis which also
provide preprimary education to these children. The food supplement provides
300 kcal and 10 grams of protein per child per day. Balwadis are being phased
out because of universalization of ICDS.
6. ICDS programme
Integrated Child Development Services (ICDS) programme Children. There is a
strong nutrition component in this programme in the form of supplementary
nutrition, vitamin A prophylaxis and iron and folic acid distribution. The
beneficiaries are preschool children below 6 years, and adolescent girls 11 to 18
years, pregnant and lactating mothers. The States and Union Territories are

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encouraged to undertake additional ICDS projects on the Central pattern to
cover more beneficiaries.
The workers at the village level who deliver the services are called Anganwadi
workers. Each Anganwadi unit covers a population of about 1000. A network of
Mahila Mandals has been built up in ICDS Project areas to help Anganwadi
workers in providing health and nutrition services. The work of Anganwadis is
supervised by Mukhyasevikas. Field supervision is done by the Child
Development Project Officer (CDPO).
7. Mid-day meal programme
The mid-day meal programme (MDMP) is also known as School Lunch
Programme. This programme has been in operation since 1961 throughout the
country. The major objective of the programme is to attract more children for
admission to schools and retain them so that literacy improvement of children
could be brought about.
In formulating mid-day meals for school children, broad principles are
(a) The meal should be a supplement and not a substitute to the home diet
(b) The meal should supply at least one-third of the total energy requirement,
and half of the protein need
(c) The cost of the meal should be reasonably low
(d) The meal should be such that it can be prepared easily in schools; no
complicated cooking process should be involved
(e) As far as possible, locally available foods should be used; this will reduce
the cost of the meal
(f) The menu should be frequently changed to avoid monotony.
8. Mid-day meal scheme
Mid-day meal scheme is also known as National Programme of Nutritional
Support to Primary Education. It was launched as a centrally sponsored scheme
on 15th August l 995 and revised in 2004. Its objective being universalization of
primary education by increasing enrolment, retention and attendance and

85
simultaneously impacting on nutrition of students in primary classes. It was
implemented in 2,408 blocks in the first year and covered the whole country in
a phased manner by 1997-98. The programme originally covered children of
primary stage (classes I to V) 1n government, local body and government aided
schools and was extended in Oct. 2002, to cover children studying in Education
Guarantee Scheme and Alternative and Innovative Education Centres also. The
central assistance provided to states under the programme is by way of free
supply of food grain from nearest Food Corporation of lndi”- godown at the rate
of 100 g. per student per day and subsidy for transport of food grain. To achieve
the objective, a cooked mid-day meal with minimum 300 Calories and 8 to 12
grammes of protein content will be provided to all the children in class I to V.
XII. NATIONAL AND INTERNATIONAL ORGANIZATIONS FOR
CHILD HEALTH
a. DEFINITION

Child welfare agency an administrative unit responsible for social work

concerned with the welfare and vocational training of children

b. PURPOSES
 To provide education of children: The organizations are helps to
provide education to the child in different levels. The basic
education has formed in the students and it continuing according to
the educational level of the students.
 To promote and conduct research: The organizations are
conducting research regarding the needs in the community. It
promote the wellbeing of the child.
 To help training and education of teachers: the teachers are
guidelines of the students. So the training is needed for the teachers
to help the students to achieve their goal.

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  To provide health support for children: the child health is important
in the future development. So the organizations are responsible for
the health of the child.
 To ensuring safety of child: The child should need safety and
security from their family and community.
 To strengthening families to successfully care for their children
I. NATIONAL CHILD WELFARE AGENCIES
1. THE INDIAN RED CROSS SOCIETY: The Indian red cross society
was established in 1920. The Headquarters is at Delhi with 700 branches
throughout India. Child welfare activities 1931 - Maternity and Child
Welfare Bureau They run various Hospitals, Bal Vikas Kendra’s, urban
health centers, MCW Polyclinics and MCW Centers, Orphanages /
Rehabilitation Homes, Schools. Red Cross Blood Transfusion Centre for
Thalassemic Children  Antenatal Screening And Prenatal Diagnosis
Programme For Thalassemia/Sickle Cell Prevention  Medical camps –
in slums & give free medicin, Sewing Centres, Youth Peer Education
Programme (Y.P.E.P.) - HIV/AIDS/STI, “Training of Trainers
programme on Child Protection and Safe Environment, Malaria
Prevention and Control Programme, Polio Eradication programme.

2. CENTRAL SOCIAL WELFARE BOARD: This is Established under

GOI 1953, with 33 State Social Welfare Board and 18,000 NGOs
financial assisted. The Services are Scheme of short stay home for
women and girls, condensed courses of education for women and girls,
Rajiv Gandhi national creche scheme for the children of working
mothers. Innovative schemes are Poverty reduction programme, Gender
equality in access to health, education and training, Child labour,
Children or Women trafficking.

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3. KASTURBA GANDHI MEMORIAL TRUST: It was established in
1945. The Central Office is at Kasturbagram, Indore with 22 branches
and 500 centres.

4. CHILD WELFARE ACTIVITY: The Educational programmes was

school and college. Hamara School project was Smile Foundation, goa,
Village service centre (gram seva kendra), Child welfare centre (bal seva
kendra), Creach (jula ghar), Training for block worker(gram karykarta
prasikshan), Nursing training, Maternity centres, Health centre (Arogya
kendra), Hospitals, Nutritious food centres, Welfare centres for children
and women

5. INDIAN COUNCIL FOR CHILD WELFARE: The programme was

established on 1952 and the Head office is at New Delhi. The programs
are Child welfare activity, National bravery awards, Learning to live
together camp, National painting competition – (honoring child artists),
Rajiv gandhi national creche scheme, Promoting and facilitating the
adoption of orphaned and abandoned children, Indira gandhi holiday
home;- Toys, clothes and books bank, Street children project,
Sponsorship programme 6- 18,income<5000.

6. BHARAT SEVAK SAMAJ: it was established in 1952 by the National

Development Agency and sponsored by the Planning Commission,
Government of India to ensure public co- operation for implementing
government plants. The activities are Welfare Extension Project (rural
and urban), Creches and Day Care-centres, Holiday Home, Maternity
Centres, Crafts and Vocational Centres for women or girl, Occupational
Therapy Institute for physically and mentally retarded children.
Preventoria (institute for sepration) for children of leprosy disease, Home
for waifs and strays(homeless and neglected children), Pre-Primary and
nursery schools, Libraries and reading rooms, Dispensaries, Milk
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 distribution centres, institutions for handicapped children. This agency
was established educational Institutions in that 2330 schools - poor and
middle class children age 3 to 5 yr and 3 - vocational and IT Education
programs and sponsor many girls Institutions and Junior and High Girls
Schools and have been Jabalpur Girls High Secondary School-1500
students are admitted

7. THE ALL INDIA BLIND RELIEF SOCIETY: This was established in

1946 and the Head office is at Lajpat Nagar at Delhi Services. It co-
ordinates the work of different institutions working for the blind. It
organizes eye relief camps and other measures for the relief of blind.

8. HIND KUSHT NIWARAN SANGH: It was established at 1925 for care

and education to leprosy patient. The Head office is at New Delhi.
Activities for children are day care services, balwadi, creach, Holiday
homes 12-16 yr. It provides recreation facilities such as play centres
public parks, childrens library, bal bhavans, children films, national
museum, hobby classes etc.

9. ALL INDIA WOMEN’S CONFERENCE: It was established in 1927

and the Head office is at Delhi.

10.Child welfare LITERACY AND EDUCATION: It Promote school

dropouts and other under privileged children to return to mainstream
education. It helps for primary education for school drop out girls and
education and day care services for street children. It promotes
condensed courses for women and girls.

11.HEALTH, FAMILY WELFARE AND POPULATION: Mobile

Health Vans Provides special care to expectant and nursing mothers, and
children. This helps to educates women about health, nutrition, sanitation,
hygiene and family welfare. It provide day care centres for leprosy
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 patients and conducting children anemia camps. The activities like
creches for children, Scholarship program for brilliant children from
lower income group. The legislative role is Sarda Act, Hindu Code Bill -
Adoptions and Maintenance Act, Devdasi prohibition Act, Factory and
Mines Act, Maternity Benefits Act.

12.INSTITUTIONS SET UP BY AIWC: The Family Planning Centre

(estd. in 1937, now the Family Planning Association of India), Save the
Children Committee the Indian Council for Child Welfare), The Amrit
Kaur Bal Vihar for Mentally Retarded Children.

13.FAMILY PLANNING ASSOCIATION OF INDIA: It was established

in 1949. The Headquarters is at Mumbai. The services provided are
Gynecological services, Infertility services, Gender Based Violence
related services, Laboratory services, Contraceptive services,
(MTP)Medical Termination of Pregnancy Services, HIV related services
like test, counselling, treatment, Maternal and child care services, Urine
pregnancy test, Antenatal care including injection TT and supplement,
counseling , post natal care and counselling, immunization services for
children, general clinic for mothers and children. The special programmes
conducting are Small Family By Choice Project-acceptance of family
planning, Youth Education on Sexuality Project awareness and education
in SRH issues, The Girl Child and Prevention of Female Foeticide
Project, Disha- Disha Centres/young people/meet, discuss healthy
lifestyles, Movement Youth to Youth-RH education/adolescents Girl/
Madrasas, Spandana-educational project /RH issues.

14.ST. JOHN AMBULANCE: Was Established in 1992. The Headquarter

is at Delhi. The activities are Organize Training Programme For First
Aid, Home Nursing, Hygiene & Sanitation. Mother craft & Child
Welfare, Disaster Management, Provide Service, Ambulance & First Aid
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 services, Awareness programmes, Arrange of first Aid Post & duties on
various Occasions and relief works during the calamities and organizing
blood camps.

15.TUBERCULOSIS ASSOCIATION OF INDIA: it was established on

February, 1939. The head office is at New Delhi. The activity was
providing quality diagnostic and treatment services, complementing
supplementing RNTCP, DOTs services of Government of India (GoI) No
new units are to be established to avoid costs and duplication.

16. FORD FOUNDATION: The ford foundation was established in 1936 at

New York and in India at 1952. The headquarter is at Dehli and the
founder was Henry & Edsel Ford. It support organizations that Promote
livelihood opportunities, Advocate for economic and social rights, Make
the government's development efforts transparent and accountable, Work
to create agricultural policies, Enable women and girls to address their
sexual and reproductive health and rights, Broaden the participation of
marginalized groups through public service media.

II. INTERRNATIONAL CHILD WELFARE AGENCIES

1. WORLD HEALTH ORGANIZATION (WHO): It was established on
7th April 1948 .The headquarter is at Geneva. The activities are Directing
and co-ordinating health programmes, Prevention and control of
communicable and other specific disease, Helping member countries in
their health programmes and development of health services, providing
more emphasis on development of infrastructure, Helping programmes
related to improvement in the standard of family health, Promoting
environmental health, Collection of data for health statics ,
communication and publication of information, Encouraging research and
help in strengthening training institute, collection and publication of
health literature and information , keeping WHO LIBRARY up to date
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 and provide community information services, National Polio Surveillance
Project, Routine Immunization, Integrated Management of Neonatal and
Childhood Illnesses, Integrated Disease Surveillance Project, RNTCP,
Emergency and Humanitarian Action, National AIDS Control Project
(NACP), Leprosy Elimination, CHILD WELFARE, National Vector
Borne Disease Control Programme, Integrated Prevention and Control of
Non Communicable Diseases, National Tobacco Control Programme,
national programme for prevention and control of cancer, diabetes,
cardiovascular disease and stroke, National Mental Health Programme
and Elimination of Lymphatic filariasis.

2. UNICEF (United Nations International Children’s Emergency

Fund): Established in 1946 by the UN general. The Headquarters is at
New York. It was active in more than 190 countries in India since 1949.
The focus area was Child survival and development, Basic education and
gender equity, HIV/AIDS and children, Child protection, Policy
advocacy and partnerships for children's right9s. The activities are
Maternal Health in India (NRHM), UNICEF support Village Health and
Nutrition Days (VHND) such as antenatal checkup, NRHM -Janani
Suraksha Yojna for institutional delivery, RCH programme to reduce
mortality. UNICEF and WHO support meseals and polio eradication,
Neonatal Health In India and Support IMNCI program. It supports setting
up and managing of Special Care Newborn Units. UNICEF assist ICDS
programme, supports iron and Vitamin A supplementation, National
Rural Drinking Water Programme, GOBI campaign, National aids control
programme – drug, staff, reporting system, UNICEF Child Protection
Programme- Labour, trafficking, marriage, abuse, Develop website for
Missing Children. Education In emergencies helps to restore education to
affected populations, partner in the Sarva Shiksha Abhiyan. It implements
a ‘quality package’ across 14 states that aims at improving the quality of
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 curricula and classroom environment, supports alternative learning
strategies including bridging courses for adolescent girls, who are out of
school.

3. INTERNATIONAL RED CROSS: Establishment at 1863. Head office

at Geneva, Switzerland. The Services are Protection of war wounded,
refugees, and prisoners. The activities are Visiting detainees, Re-uniting
families, Promote ensuring economic security, Water and habitat
activities, Safeguarding health care, Reducing the humanitarian impact of
weapon contamination, Health helps ensure continuation of basic health
services, First Aid, Emergency transport and hospital care, mother and
child care, vaccination, health and hygiene promotion, Strengthen
hospital management, Blood donation,Drug and equipment supply.

4. FAO OF THE UNITED NATIONS: Establishment: - 16 October 1945

 headquarter in Rome, Italy. FAO has 191 Member Nations. The
services provided by FAO is also a source of knowledge and information,
and it helps developing countries in transition modernize and improve
agriculture, forestry and fisheries practices. It ensuring nutrition and food
security for all child welfare. ILO & FAO working together to prevent
Child Labor in Agriculture and fisheries

5. WORLD BANK: The World Bank is an international financial agency of

the United Nations that provides loans to developing countries for capital
programs to rise living standard. It was established in 1944. The
headquarter is at Washington. The functions of world bank is Bank gives
loan for projects that lead to economic growth the projects usually
concern with economic growth, Agriculture, water supply, education,
Road, railway, electricity, family planning, Health and environment,
health assistance to hospital care. Cooperative programmes exist between

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 WHO and the world Bank e.g. projects for water supply, World Food
Programme, Population control programme etc.

6. CARE (Cooperative For American Relief Everywhere): it was

established in 1945 and Headquartered at Atlanta, Georgia. It work in 84
countries. The services provided by care are logistics, food aid, and long
term development assistance. In INDIA care work with govt of india ,
state govt, NGO and it also support following projects. It support ICDS
programme, Integrated and nutritional programme, Better health and
nutritional programme, Anemia controle project, Improving womens
health projects, Improved health for adolcencent girl project, Child
survival project, Improving womens reproductive health and family
spacing project, Konkan integrated development project. It provide Girls’
Education Programme, Udaan school –9-14 girl/primary
education/11month, Kasturba Gandhi Balika Vidyalayas, Support ICDS
programme implementation HEALTH, SAKSHAM AND EMPHASIS-
NACP, AXSHYA –RNTCP, Family Health Initiative, SWASTH -Tech
Assist /Nutritional Programme, SEHAT which improve nutrition and
health status of women & children, Urban Health Initiative –MD Goals,
Join My Village -maternal and newborn health, increasing community
participation, building capacities of service providers.

7. USAID (UNITED STATES AGENCY FOR INTERNATIONAL

DEVELOPMENT): Establishment at 3 nov.1961 and Headquarters at
Washington. It works in over 100 countries. The services are, Promote
economic prosperity, Strengthen democracy and good governance,
Protect human rights, Improve global health, Advance food security and
agriculture, Improve environmental sustainability, Further education,
Help societies prevent and recover from conflicts/disaster. In India
USAID implements HIV/AIDS prevention, care and treatment

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 programme, supports implementation of the DOTs, technical support to
immunizations and Vit A, food aid program, support RCH services of
NRHM, supports the National Polio Surveillance Project, Support Polio
Eradication programme.

8. UNDP (UNITED NATIONS DEVELOPMENT PROGRAMME): It

was established in 1966. The headquarters at New York. It work with 177
countries. The working areas are poverty reduction, achieving the
Millennium Development Goals, democratic governance, crisis
prevention and recovery, environment and energy protection, UNDP
works closely with the National AIDS Control Programme of India,
Women's Empowerment and Inclusion, Human Development.

9. UNFPA (United Nations Fund For Population Activities): It was

established at 1969 Head office is at New York. The Mission of UNFPA
is the United Nations Population Fund, delivers a world where every
pregnancy is wanted, every birth is safe, every young person's potential is
fulfilled. In INDIA the UNFPA was aim for Reproductive and Child
Health II (RCH II), National AIDS Control Programme III (NACP III),
National Rural Health Mission (NRHM).

10.INTERNATIONAL LABOR ORGANIZATION: it was established at

1919 at Geneve. Its main aims are to promote rights at work, encourage
decent employment opportunities, enhance social protection and
strengthen dialogue on work-related issues.

11.WORK FOR CHILD WELFARE: Child Labour was concentrating on

the ILO's International Programme on Child Labour (IPEC) works to
achieve the effective end of child labor through country-based
programmes. INDUS (India-US) Child Labour Project and prevention
and elimination of child labour. The Child Welfare Service is responsible

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 for implementing measures for children and their families in situations
where there are special needs in relation to the home environment.
Assistance may be provided as counseling, advisory services, and aid
measures, including external support contacts, relief measures in the
home, and access to day care and agencies or organization play an
important role in delivery of child welfare services.

SOCIAL ISSUES RELATED TO CHILDREN

Children are the future and it is the responsibility of adults to protect them and
ensure that they get the best footing in life. Unfortunately this is not always the
case in many nations around the world – including our own!

Terrible issues facing by children including the following.

1. Child Labour
Child labour may be defined as employment of children in gainful occupation
even at the expense of their physical, emotional and social wellbeing. Child
labours have consequences on their growth and development and health status
resulting various health hazards:
Numbers of child labour are increasing. India has the largest number of child
labours in the world, among them 90% are from rural areas. The factors
responsible for this problem are mainly poverty, lack of education,
unemployment, exploitation by selfish and lazy parents, broken family, death of
parents.
There are number of health hazards resulting in working children, which include
hygienic problem, drug addiction, smoking, alcoholism, STDs, juvenile
delinquency even prostitution.
Child labour is a social problem and need special attention from all levels to
eliminate the basic causes behind it. Indian constitution emphasized on
protection against exploitation in childhood. The child labour protection and

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regulation act 1986, provides guidelines about the restriction related to child
labout the supreme court of India, in 1996 directed all state government and
union territories to take concrete steps to abolish child labour and instructed for
setting up of child labour rehabilitation welfare fund. Elimination of child
labour can only be possible with combined effort of parent, community,
government, non government and voluntary agencies.

An estimated 211 million children between the ages of 5 and 14 are working
around the world, according to the International Labour Organization. Of these,
120 million children are working full time to help support their impoverished
families.
2. Street children
A large number of homeless children are seen as pavement dwellers in urban
and semi urban areas, they live and work on the streets usually family or with
family. These children are vulnerable to various health problems and
psychosocial problems.
These children need support form government and NGOs o overcome their
problems and to grow as a healthy individual.
3. Gender bias
Gender bias or discrimination against females is more prominent India.
Discrimination against girl child stats before birth as female feticide and
afterwards as female infanticide and inappropriate rearing of girl child.
4. Female foeticide
It is a challenging social problem related to gender bias, ultrasonography and
amniocentesis facilities during pregnancy help to detect the sex of the unborn
foetus. This practice is observed in all socioeconomic groups, as an affinity to
male child or son complex. It also influenced by dowry system and fear of
sexual victimization of girl child. Prenatal diagnostic technique (regulation and
prevention of misuse) act 1994 came in to force to ban this problem.

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5. Child abuse
Child abuse includes physical violence (75%), sexual molestation (20%),
mental and emotional (20%), maltreatment with negligence, deprivation or lack
of opportunity. The children are abused at home, school, day care centres. The
child abuse may be found in the form of battered baby syndrome. It is a clinical
condition in young children especially below 3 years of age, who have received
non accidental injury wholly inexcusable violence or injury on one or more
occasion, including minimal as well as severe fatal trauma, by the hand of an
adult. In a position of trust generally a parent, guardian or foster parent. In
addition to physical injury thee may be deprivation of nutrition, routine care,
love and affection.
6. Refugees
War is the primary factor in the creation of child refugees. It is also a principle
cause of child death, injury, and loss of parent. In the last decade, war has
killed more than 2 million children, wounded another 6 million, and orphaned
about 1 million. Children also flee their homes because they fear various forms
of abuse such as rape, sexual slavery and child labour. Circumstances of birth
also play a role in depriving children of a legal home.
7. Poverty
According to UNICEF 25000 children die each day due to poverty. Around
27-28 percent of all children in developing countries are estimated to be
underweight or stunted
8. Lack of access to school
More than 100 million children do not have access to school. For socially
disadvantaged segments of the population like poor inhabitants of cities, AIDS
orphans and the physically challenged, any access to education is often
particularly difficult to obtain.
The consequence of this lack of access to education is that 15 percent of those
adolescents between 15 and 24 in third world countries are illiterate.

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9. Child Neglect
Neglect is an act of omission or the absence of action. It usually involves
infants and young children who cannot speak themselves.
Emotional neglect in tis most serious form, can result in the “non-organic
failure to thrive syndrome”, a condition in which a child fails to develop
physically or even to survive.
Parental neglectful behaviors include not keeping the child clean, not providing
enough clothes for keeping warm, not making sure the child attended school,
not caring if the child got into trouble in school, not helping with homework,
not helping the child do his best, not providing comfort when the child was
upset, and not helping when the child had problems.
10. Child prostitution
A study by the International Labor Organization on child prostitution in
Vietnam reported that incidence of children in prostitution is steadily increasing
and children under 18 make up between 5 percent and 20 percent of prostitution
depending on the geographical area.
The median age for entering into prostitution among all children interviewed
was 13 years.
11. Military use of children
Around the world, children are singled out for recruitment by both armed forces
and armed opposition groups, and exploited as combatants. Approximately
250,000 children under the age of 18 are thought to be fighting in conflicts
around the world, and hundreds of thousands more are members of armed
forces who could be sent into combat at any time.
Although most child soldiers are between 15 and 18 years old. Significant
recruitment starts at the age of 10 and the use of even younger children has been
recorded.

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12. Trafficking & Slavery
Trafficking is the fastest growing means by which people are forced into
slavery. Currently children are trafficked form countries such as Bangladesh,
Pakistan, Sudan and Yemen to be used as camel jockeys in the UAE.
The use of children as jockeys in camel racing is itself extremely dangerous
and can result in serious injury and even death. Some children are also abused
by the traffickers and employers, for example by depriving them of food and
beating them. The children’s separation from their families and their
transportation to a country where the people, culture and unusually the language
are completely unknown leaves them dependent on their exployers and de fact
forced labourers.

XIV. NURSES RESPONSIBILITIES IN PREVENTIVE PAEDIATRICS

Paediatric nurse has a unique opportunity to work with parents and children the
family and community to provide good environment and adequate facilities to
promote health and prevent childhood illness to attain their fullest potentials.
Preventive care is better render by nurses by health assessment, health
education, health counseling, anticipatory guidance, direct nursing care and
referral.

Nurses should follow steps of nursing process i.e. assessment, Nursing

diagnosis, planning, implementation and evaluation while providing care to
children to attain, maintain and restore health.

The pediatric nurses’s role is unique because of developmental immaturity and

vulnerability of children. The goals of nursing care of children, based on
primary health care are:

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 primary care
giver
nurse health
researcher teacher

nurse
consultant
care nurse
counsellor

nurse
recreationist giver social
worker

co-ordinator
nurse &
manager
child care collaborator
advocate

Fig. 5 Role of nurse

1. Primary Caregiver: Pediatric nurses are providing basic care to children

Like hospitalized Child physical, Growth and developmental assessment,
Immunization, feeding. It should be focused on

1. Preventive aspect of care

2. Promotive aspect of care

3. Curative aspect of care

4. Rehabilitative aspect of care

2. Health Teacher: A child health teaching is very basic duty for nurses
since they are the ones responsible for monitoring the child as well as carry out
the Physician’s discharge orders. She must be anticipating parent’s doubts
regarding improvement of their children’s health status such as parenting and
disease process so as to prevent future hospital admission as such as much as
possible.
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3. Nurse Counsellor : On Providing guidance to parents in health hazards
of children and health them for own decision making in different situations.
Nurse counsellor must be active listeners in order to establish a therapeutic
relationship between parents and child, making health care plans easier.
Nurse counsellor will be solving the parent’s problem towards their child care.
She help the parents to take the independent decision for betterment of their
child health care.
4. Social Worker : Pediatric nurse can participate in social services or refer
child family to Child welfare agencies for necessary support. In child health
care, sometimes, pediatric nurse act as a social worker, try to reduce the social
problems which is going to affect the child health. She should guide the parents
related to child welfare agencies for improvement of Child health.
5. Coordinator and Collaborator: Pediatric nurses are sometimes or most
of the time works with other health care team members, where he or she is the
avenue of important information that other health team members need in
delivering competent care. 80 it is a must that pediatric nurses need to be a good
information giver and communicator among health team members to promote a
harmonious working environment.
There are many roles that a pediatric nurse could perform as health care settings
evolved from one stage to another. The challenge lies behind the application of
evidenced-based practice to provide competent care to children. Last but not the
least, having a heart for children matters a lot when the work load at the area
seems to be heavy children could make you smile no matter how harsh the
world could be.
6. Child Care Advocate : Pediatric nurses are expected to be sensible
enough in voicing out the needs of their child and folks in behalf of them when
it is impossible for them to readily address their needs. She can help the child
and parents to receive the best quality of care from the hospital.

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7. Nurse Manager: A pediatric nurse managers should help the child and
parents by managing the nurses who care for them. While these nurses are
mainly responsible for recruitment and retention of the nursing staff and
overseeing them, they should be collaborate with doctors on child care, and help
to assist child and their families when needed.
8. Nurse Recreationist : The pediatric nurse plays supportive role for the
child to provide play facilities for recreation and diversion. It helps to decrease
crisis imposed by illness or hospitalization.
9. Nurse Consultant: The pediatric nurse can act as consultant to guide
parents and family members for maintenance and promotion of health. For
example, Guiding parents about feeding practices, accident prevention,
drowning and childhood poisoning.
10. Nurse Researcher: Pediatric nurse researchers are more important in
pediatric nursing field for improvement Of Child health status. A change is
constant in the health care setting, so it is must to practice evidenced-based
practice. This means that pediatric nurses should have the ability to improve
themselves in order to give updated care to children.

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XV. SUMMARY

Preventive pediatrics comprises efforts to avert rather than cure disease and
disabilities. It has been broadly divided into antenatal pediatrics and postnatal
pediatrics. The aims of preventive pediatrics and preventive medicine are the
same: prevention of disease and promotion of physical, mental and social well-
being of children so that each child may achieve the genetic potential with
which he/she is born. To achieve these aims, hospitals for children have adopted
the strategy of “primary health care to improve child health care through such
activities as growth monitoring, oral rehydration, nutritional surveillance,
promotion of breast feeding, immunization, community feeding, regular health
check-ups, etc. Primary health care with its potential for vastly increased
coverage through an integrated system of service delivery is increasingly looked
upon as the best solution to reach millions of children, especially those who are
most in need of preventive and curative services. Another new concept of child
health care is social pediatrics. The challenge of the time is to study child health
in relation to community to social values and to social policy. Social pediatrics
has been defined as “The application of the principles of social medicine to
pediatrics to obtain a more complete understanding of the problems of children
in order to prevent and treat disease and promote their adequate growth and
development, through an organized health structure. It is concerned with the
delivery of comprehensive and continuous child health care services and to
bring these services within the reach of the total community.

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XVI. CONCLUSION

Children are major consumers of health care. In India about 35% of total
population are children below 15 years of age. They are not only large in
number but also vulnerable to various health problems and considered as special
risk group. Majority of childhood sickness and death are preventable by simple
low cost measures. Preventive pediatrics been broadly divided into antenatal
preventive pediatrics and postnatal preventive pediatrics. Antenatal preventive
pediatrics includes care of the pregnant mothers with adequate nutrition,
prevention of communicable diseases, preparation of the mother for delivery,
breastfeeding and mother craft training, etc, pre pregnant health status of the
mother also influences the child health. Promotion of health of girl child and
non pregnant state should be emphasized as the future mother, who is soil and
seed of future generation. Postnatal preventive pediatrics includes promotion of
breastfeeding, introduction of complementary feeding in appropriate age,
immunization, prevention of accidents, tender loving care with emotional
security, growth monitoring, periodic medical supervision and health check-up,
psychological assessment, etc.

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XVII. BIBLIOGRAPHY

1. Ghai. O.P. The text book of Essential pediatrics. 7 th edition, CBS

publishes&distribbuters Pvt Ltd,23-41
2. Gupte Suraj. The text book of Short textbook of pediatries. 10 th edition.
Jaypee publications, 31-61
3. Sharma Rimple .The text book of Essentials of pediatric Nursing. 2 nd
edition, Jaypee publication,49-71
4. Gupta Piyush. the text book of PG text book of pediatrics Volume 1.The
health science publisher, 701-736
5. Marlow. R. Dorothy, Reding A. Barbara, The text book of “Pediatric
Nursing: 6th edition saunders an infants of Esevier, 547-598
6. Yadav Manoj, The text book of “chld Health Nursing, 2013 edition PV
books publishers,69-132
7. Varghese Susamma, Susmitha Anupama. (2015). Text book of Pediatric
Nursing. 1st Edition. New Delhi: Jaypee publications,41-42
8. Sudhakar a. ( 2017). Essentials of pediatric nursing. 1 st edition. New
delhi.Jaypee publications, 21-23.

Journal reference

1. Lovejoy.JR. Introduction to preventive paediatrics. 1984 Nov: 74(5 Pt

2):958-60.
2. Earnestine Willis. Preventive Pediatrics Issues for Child Health Care
Providers. October 2015. Volume 62, Issue 5, p1071-1362

Internet sources

1. https://www.jpeds.com/article/S0022-3476(63)80320-0/abstract

2. https://jamanetwork.com/journals/jamapediatrics/article-abstract/500724

3. https://www.pediatric.theclinics.com/issue/S0031-3955(14)X0011-8

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