diff --git "a/notes/Ghai-Essential-Pediatrics_20.txt" "b/notes/Ghai-Essential-Pediatrics_20.txt" new file mode 100644--- /dev/null +++ "b/notes/Ghai-Essential-Pediatrics_20.txt" @@ -0,0 +1,2132 @@ +possible, feel for fever or low body on the way to the hosp/ta/ +temperature) , Refer URGENTLY to hospital +• See if the young infant is lethargic or +unconscious Palms and soles not yellow JAUNDICE ,. Advise mother to give home care for the young infant +• +Look at the young infant's movements. ,. Advise mother when to return immediately +Are they less than normal? ,. Followup in 2 days +• +Look for jaundice. +Are the palms and soles yellow? + + +m ll +ll +fl +:s + +ti +0. +- +.. +fl +ii' c;· + + + + + +1If referral is no/ possible, see the section Where Referral Is Not Possible in the module Treat the Young Infant and Counsel the Mother + + +And if the temperature is between +35.5 and 36.4"C + + +Temperature between 35.5 and 36.4°C +LOW BODY +!TEMPERATURE + +,. Warm the young infant using skin-to-skin contact for one hour and REASSESS +If no improvement, refer +, Treat to prevent low blood sugar + + + + +Contd... + + +Chart 30.1 (Contd.) + + + +THEN ASK: +Does the young infant have diarrhea?* + +IFYES,ASK: LOOKAND FEEL: + +• For how long? • Look at the young infant's general +• Is there blood in condition. Is the infant: +the stool? - lethargic or unconscious? - Restless and irritable? +• Look for sunken eyes +• Pinch the skin of the abdomen Does it go back: +-Very slowly (longer than 2 seconds)? +-Slowly? + + + + + + + + + + + + +• What Is diarrhea In a young Infant? +If the stools have changed from usual pattern and are many and watery (more waler than fecal matter). The normally frequent or loose stools of a breastfed baby are not diarrhea + + + +for DEHYDRATION + + + + + +Classify DIARRHEA + + + + + + + + + + + +and if diarrhea +14 days or more + + +Two of the following signs: +• Lethargic or unconscious +• Sunken eyes +• Skin pinch goes back very slowly + + + + +Two of the following signs: +• Restless, 1mtable • Sunken eyes +• Skin pinch goes back slowly + + + +Not enough signs to classify as some or severe dehydration + + +Diarrhoea lasltng 14 days or more + + +, Give first dose of intramuscular ample/I/In and gentamlcln r II Infant also has low weight or another severe +SEVERE classification: +DEHYDRATION - Refer URGENTLY to hospital with mother giving frequent +sips of ORS on the way +- Advise mother to continue breastfeeding +- Advise mother how to keep the young Infant warm on the way to the hospital +OR +, If infant does not have low weight or any other severe classification: +- Give fluid for severe dehydration (Plan C) and then refer to hospital after rehydration +,. ff Infant also has low weight or another severe classification - Give first dose of Intramuscular amplclllln and gentamlcln +SOME - Refer URGENTLY to hospital with mother giving frequent DEHYDRATION sips of ORS on the way +-Advise mother to continue breastfeeding +-Advise mother how to keep the young Infant warm on the way to the hospital +,. If infant does not have low weight or another severe classification--Give fluids for some dehydration (Plan B) +-Advise mother when to return immediately -Followup in 2 days +"" Give fluids to treat diarrhea at home (Plan A} NO -,. Advise mother when to return immediately +DEHYDRATION , Followup in 5 days if not improving + + +, Give first dose of Intramuscular ampiclllin and gentamlcin +If the young Infant has low weight, dehydration or another +SEVERE severe classlflcatlon PERSISTENT , Treat to prevent low blood sugar +DIARRHEA , Advise how to keep infant warm on the way to the hospital +., Refer to hospital• + + + + + + + + + + + + +S" +S' +:a +iJ +S' +C. +!: +D> +:I +D> +CD +3 +- +a +CD + +I) +:I + +z +I) +0 +:I +D> + + + + + +•11 referral is not possible, see the section Where Referral ls Not Possible in the module Treat the Young Infant and Counsel the Mother + + +and if blood in stool + + +Blood in the stool SEVERE DYSENTERY + +,. Give first dose of intramuscular amplcilUn and gentamlcln If the young Infant has low weight, dehydration or another severe classlflcatlon +, Treat to prevent low blood sugar +,. Advise how to keep Infant warm on the way to the hospital +,. Refer to hospital• + + +D> +:, +Q. +0 +a: +== +:r +0 +0 +Q. +:i +Advise mother when to return Immediately +l> Praise the mother for feeding the infant well + + +'If referral is not possible, see the section Where Referral Is Not Possible in the module Treat the Young Infant and Counsel the Mother +Integrated Management of Neonatal and Childhood Illness + + + +Clinical Assessment and Classification +All infants with diarrhea should be assessed for presence of dehydration. A number of clinical signs are used to determine the level of dehydration: infant's general condition (lethargic or unconscious or restless/irritable); sunken eyes and elasticity of skin (sin pinch goes back very slowly, slowly or immediately). In addition the infant is assessed for persistent diarrhea and dysentery. +Persistent diarrhea is an episode of diarrhea, with or without blood, which begins acutely and lasts at least 14 days. Persistent diarrhea is usually associated with weight loss and often with serious nonintestinal infections. Persistent diarrhea in a young infant is considered as severe illness and requires urgent referral. Similarly, visible blood in stool in a young infant is classified as severe dysentery and the infant should be referred to hospital. +All young infants with diarrhea are classified for degree of dehydration and in addition may be classified if they have persistent diarrhea and/or dysentery. Young infants with severe dehydration will need IV fluids while those with some dehydration are treated as plan B with oral rehydration. Young infants with no dehydration will require more fluid to prevent dehydration (see Chapter on diarrhea). + +Checking for Feeding Problems or Malnutrition +All sick young infants seen in outpatient health facilities should be routinely evaluated for adequate feeding and have their weight checked. Weight-for-age compares the young infant's weight with the infants of the same age in the reference population (WHO-NCHS reference). The very low weight-for-age or severely underweight identifies children whose weight is -3 standard deviations below the mean weight of infants in the reference population (Z score <-3). The low weight for age or moderately under­ weight identifies children whose weight is -2 standard deviations below the mean weight of infants in the refer­ ence population (Z score <-2). Infants who are very low weight for age are given pink classification and should be referred to a hospital. Infants who are low weight for age need special attention to how they are fed and on keeping them warm. +To assess the young infant for feeding problems the mother is asked specific questions about infant feeding to determine if the feeding practices are optimal. The weight of the child and feeding history is taken into consideration to determine if breast feeding technique needs to be checked. Thus an exclusively breastfed infant who is not low weight for age does not require any intervention and is therefore not observed for breastfeeding. If the mother gives history of feeding problem or the infant is low weight for age and has no indication for referral the mother is observed for breastfeeding. Breastfeeding is observed to see the signs of attachment and whether the infant is suckling effectively. Mothers of infants with problem in + +feeding are counseled appropriately. Infants who are not low weight for age and have no feeding problem are classified as 'no feeding problem' and counseled about home care of young infant. + +Checking Immunization Status +Immunization status should be checked in all sick young infants. A young infant who is not sick enough to be referred to a hospital should be given the necessary immunizations before he is sent home. + +Assessing Other Problems +All sick young infants need to be assessed for other potential problems mentioned by the mother or observed during the examination. If a potentially serious problem is found or there are no means in the clinic to help the infant, he should be referred to hospital. + +Identify Treatment and Treat +The next step is to identify treatment required for the young infant according to the classification. All the treatments required are listed in the 'Identify Treatment' column of the ASSESS and CLASSIFY THE SICK YOUNG INFANT, Chart 30.1. If a sick young infant has more than one classification, treatment required for all the classifications must be identified. The first step is to determine if there is need to refer the child to hospital. +All infants and children with a severe classification (pink) are referred to a hospital as soon as assessment is completed and necessary pre-referral treatment is administered. Successful referral of severely ill infants to the hospital depends on effective counseling of the caretaker. The first step is to give urgent prereferral treatment (written in bold font in identify treatment section of chart). This may be: • Administering first dose of antibiotic +• Treatment of severe dehydration +• Warming the young infant using skin-to-skin contact (kangaroo mother care) and keeping the infant warm on the way to the hospital +• Prevention of hypoglycemia with breastmilk; if young +infant is not able to swallow give expressed breast milk/ appropriate animal milk with added sugar by nasogastric tube +I +• In young infants with diarrhea, giving frequent sips of ORS solution on the way to the hospital. + +Treatment in Outpatient Clinic and at Home +Young infants who have local infection, feeding problem or low weight, or diarrhea with some dehydration should have treatment initiated in clinic which is to be continued at home (Table 30.1). Counseling a mother/caretaker is critical for home care. The health professional should use good communication skills while counseling the mother/ caretaker for treatment (Box 30.1). +..e.s.s.e .nt•ia•P•e•d•i-atr..ic______________________________ +l +s +- + + +Table 30.1: Treatment guidelines for managing sick young infant in outpatients and at home +Treatn1.ent of local infections +- Local bacterial infection: Give oral amoxicillin N cotrimoxa­ zole or x 5 days (avoid cotrimoxazole in infants 1 month of age who are premature or jaundiced) +- Skin pustules or umbilical infection: Teach to apply gentian violet paint twice daily at home. +- Discharge from ear: Teach to dry the ear by wicking +Some and no dehydration +- Treat dehydration as per WHO guidelines for treatment of dehydration. +Feeding problem or low weight +- Skin pustules or umbilical infection: Teach to apply gentian Teach correct positioning and attachment for breastfeeding Teach the mother to manage breast and nipple problems Treat thrush: Tell the mother to paint the mouth of the young infant with gentian violet 0.25% twice daily +Feeding with a cup and spoon: Wherever indicated teach the mother correct technique of feeding +Counsel the mother/caretaker about other feeding problems. +Keep the young infant warm +- Teach the mother how to keep the young infant with low weight or low body temperature warm (do not bathe the young infant but sponge with lukewarm water to clean, provide skin to skin contact; keep the room warm: clothe the baby in 3-4 layers properly covering the head with a cap and hands and feet with gloves and socks respectively, cover the baby and the mother with additional quilt or shawl, especially in cold weather). + + +Box 30.1: Effective communication and counseling-APAC +• Ask and listen: Ask the mother/ caretaker and listen carefully to find out the young infant/ child's problems and what the mother/caretaker is already doing for the young infant/ child +• Praise: Praise the mother/ caretaker for what she has done well +• Advise and teach: Advise the mother/caretaker how to take care of young infant/ child at home (for tasks which require mother/ caretaker to carry out treatment at home: give information, show an example, and let her practice) +• Check: Before the mother/ caretaker leaves, always check her understanding by asking questions to find out what she understands and what needs further explanation + +OUTPATIENT MANAGEMENT OF SICK CHILD AGE 2 MONTHS UP TO 5 YEARS +Assess and Classify Sick Child +The assessment procedure is similar to that of young infant +including: (i) history taking and communicating with the caretaker about the child's problem; (ii) checking for general danger signs; (iii) checking main symptoms; (iv) checking for malnutrition; (v) checking for anemia; (vi) assessing the child's feeding; (vii) checking immunization status; and (viii) assessing other problems (Chart 30.2). + +Checking for General Danger Signs +A sick child brought to an outpatient facility may have signs that clearly indicate a specific problem. For example, a child may present with cough and chest indrawing which indicate severe pneumonia. However, some children may present with serious, nonspecific signs called General Danger Signs that do not point to a particular diagnosis. For example, a child who is lethargic or unconscious may have meningitis, severe pneumonia, cerebral malaria or any other severe disease. Great care should be taken to ensure that these general danger signs are not overlooked because they suggest that a child is severely ill and needs urgent attention. The following general danger signs should be routinely checked in all children: (i) history of convulsions during the present illness, (ii) unconsciousness or lethargy, (iii) inability to drink or breastfeed when mother tries to breastfeed or to give the child something to drink, and (iv) child vomits everything. +If a child has one or more of these signs, he must be consi­ dered seriously ill and will almost always need referral. In order to start treatment for severe illnesses without delay, the child should be quickly assessed for the main symptoms and malnutrition and referred urgently to a hospital. + +Assessing for Main Symptoms +After checking for general danger signs, the health care provider must enquire about the following main symp­ toms: (i) cough or difficult breathing; (ii) diarrhea; (iii) fever; and (iv) ear problems. If the symptom is present the child is evaluated for that symptom (Chart 30.2). +Cough or dificult breathing A child with cough or diffi­ cult breathing may have pneumonia or severe respiratory infection. In developing countries, pneumonia is often due to bacteria. The most common are Streptococcus pneumo­ niae and Haemophilus infiuenzae. Many children are brought to the clinic with less serious respiratory infections. Most children with cough or difficult breathing have only a mild infection. They do not need treatment with antibiotics. Their families can manage them at home. Very sick children with cough or difficult breathing need to be identified as they require antibiotic therapy. Fortunately, one can identify almost all cases of pneumonia by checking for these two clinical signs: fast breathing and chest indrawing. Chest indrawing is a sign of severe pneumonia. +Clinical assessment and classification. A child presenting with cough or difficult breathing should first be assessed for general danger signs. This child may have pneumonia or another severe respiratory infection. Three key clinical signs are used to assess a sick child with cough or difficult breathing: fast breathing ( cut-off respiratory rate for fast breathing is 50 breaths per minute or more for a child 2 months up to 12 months, and 40 breaths per minute or more for 12 months up to 5 yr); lower chest wall indrawing and stridor in a calm child. Based on a combination of the above clinical signs, children presenting with cough or difficult +Chart 30.2 +ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS + +ASSESS + +ASK THE MOTHER WHAT THE CHILD'S PROBLEM ARE? + +• Determine if this is an initial or followup visit for this problem +If follow-up visit, use the followup instructions on TREAT THE CHILD chart If initial visit, assess the child as follows: + + +CLASSIFY IDENTIFY TREATMENT + + +CHECK FOR GENERAL DANGER SIGNS + +ASK: LOOK: + +• Is the child able to drink or breastfeed? See if the child is lethargic or unconscious • Does the child vomit everything? +• Has the child had convulsions? + + +A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral Is not delayed + + +USE ALL BOXES THAT MATCH THE +CHILD'S SYMPTOMS AND PROBLEMS +al +TO CLASSIFY THE ILLNESS SQ-. + +I:I»», +ClQ) + + + +THEN ASK ABOUT MAIN SYMPTOMS: SIGNS +Does the child have cough or difficult breathing? • Any general danger sign, or +• Chest indrawing, or +Classify +IFYES,ASK: LOOK, LISTEN: � • Strider in calm child COUGH or +} +For how long? , Count the breaths in one CHILD DIFFICULT +/ +minute +, Look for chest indrawing MUST BE BREATHING +, Look and listen for strider CALM Fast breathing + + + +If the child Is: Fast breathing Is: +2 months up 50 breaths per No signs of pneumonia to 12 months mmute or more or very severe disease. +12 months up 40 breaths per to 5 years minute or more + + +CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print) + +SEVERE ,. Give first dose of Injectable chloramphenlcol +PNEUMONIA (If not possible give oral amoxici1/n) +OR VERY , Refer URGETLY to hospital 1 SEVERE DISEASE + +, Give Amoxicillin for 5 days +, Soothe the throat and relieve the cough with a safe remedy if child is 6 mo or older +PNEUMONIA +, Advise mother when to return immediately +, Followup in 2 days + +, If coughing more than 30 days, reler for assessment ,Soothe the throat and relieve the cough with a safe +NO PNEUMONIA: +home remedy if child is 6 mo or older +COUGH OR COLD .-Advise mother when to return immediately ,Fol\owup in 5 days if not improving + +l) +:, +a + +z +l) +0 +:, +I» + +I» :, +Q. =­ +0 +CL +:r +0 +0 +Q. + +l) I) +I) + + +'If referral is not possible, see the section Where Referral Is Not Possible in the module Treat the Child + +Contd. + + + + + + + +Does the child have diarrhea? + +IF YES, ASK: LOOK AND FEEL: for +DEHYDRATION • For how long? • Look al the child's general +condition +• Is there blood in Is the child: +the stool? Lethargic or unconscious? Restless and irritable? + +• Look for sunken eyes + +Chart 30.2 (Contd.) + + + +Two of the following signs: , If child has no other severe classification: +> +• Lethargic or unconscious - Give fluid for severe dehydration (Plan C) +• Sunken eyes , If child also has another severe classification: +, +• Not able to dnnk. or SEVERE Refer IJRGENTL Y to hospitat with mother giving frequent +dnnking poorly DEHYDRATION sips of ORS on the way. Advi&e the mother to continue +• Skin pinch goes back very breastfeeding +I +slowly , If child Is 2 years or older and there Is cholera In your area, I give doxycycline for cholera + + +m +- +ll +ll I) +:I +.: +:, +Q. +- +.. +I) ii' +ci' +ll + + + +Offer the child fluid Is the child: +Not able to drink or drinking oorly? +Drinking eagerly, thirsty? + +• Pinch the skin of the abdomen Does tt go back: + +Very slowly (longer than 2 seconds)? +Slowly? + + +Classify DIARRHEA + + +Two of the following signs: • Restless. irritable +• Sunken eyes +• Drinks eagerly, thirsty • Skin pinch goes back +slowly + +Not enough signs to classify as some or severe dehydration + + +, Give fluid and food for some dehydration (Plan B) , If child also has a severe classification: +Refer IJRGENTL Y to hospital' with mother giving frequent ps d RS on he WY· se he er ID ue breastfeeding +SOME +DEHYDRATION +, Advise mother when to return immediately +, Followup in 5 days if not improving + +NO , Give fluid, zinc supplements and food lo treat diarrhea at +DEHYDRATION home (Plan A) +, Advise mother when to return immediately +, Followup in 5 days if not improving + + + +and if diarrhea 14 days or more + + +Dehydration present SEVERE +PERSISTENT +DIARRHEA + +, Treat dehydration before referral unless the child has another severe cluslflcatlon +, Refer to hosp1ta1• + + + + + + + +and if blood in stool + + + +'If referral is not possible. see the section When, Referral Is Not Possible in the module Treat the Child + + +No dehydration + +I Blood in the stool + +PERSISTENT DIARRHEA + + + +DYSENTERY + +I + + +, Advise the mother on feeding a child who has PERSISTENT DIARRHEA +, Give single dose of vitamin A +, Give zinc supplements daily for 14 days , Followup in 5 days + +, Treat for 3 days with ciprofloxacin , Treat dehydration +, Give zinc supplements daily for 14 days +, Followup in 2 days + + + + +I + + + + + + + + +Contd. + + +Chart 30.2 (Contd.) + + + +Does the child have fever? (by history or feels hot or temperature 37.s•c• or above) + +' +IFYES: +Decide Malaria Risk: High or Low +THEN ASK: LOOK AND FEEL: + +• Fever for how long? • Look or feel for stiff neck + +HIGH MALARIA RISK +• Any general danger sign.or +High +� +MalariaR • Stiff neck, or +• Bulging +� fontanel +L + +Fever (by history. or +feels hot. or +temperature 37 .s·c +Classify or above) FEVER + + + +VERY SEVERE FEBRILE DISEASE + + + +MALARIA + + +l>Glve first dose of IM quinine after making a blood smear/ RDT +l> Give first dose of IV or IM chloramphenlcol (ff not possible, give oral +amoxlclllln) +l> Treat the child to prevent low blood sugar +l> Give one dose of paracetamol In clinic for high fever (temp. 38.5°C or above) l> Refer URGENTLY to hospital' +,. Give oral antimalarials for HIGH malaria risk area after making a blood smear ,Give one dose of paracetamol In clinic for high fever (temp. 38.5°C or above) :.. Advise mother when lo return immediately +l>Followup in 2 days if fever persists +:, If fever is present everyday for more than 7 days, refer for assessment + + + +• If more than 7 days, has fever been present everyday? + +• Look and feel for bulging fontanelle + + +- LOW MALARIA RISK + + + +• Has the child had measles • Look for runny nose • Any general danger l> Give first dose of IM quinine ater making a blood smear +Look for signs of MEASLES • Stiff neck, or VERY SEVERE l> Give first dose of IV or IM chloramphen/col (ff not possIble, give oral +'··=> +Malaria Risk +within the last 3 months? +sign.or +FEBRILE +amoxlclllln) +• Bulging DISEASE l> Treat the child to prevent low blood sugar +• Generalized rash and +38.s•c +l> Give one dose of paracetamol In clinic for high fever (temp. or above) +fontanel +• One of these: cough, runny nose, l> Refer URGENTLY to hospital' +or red eyes +• NO runny nose. and ;. Give oral antimalarials for LOW malaria risk area after making a blood smear I RDT +If the child has measles • Look for mouth ulcers • NO measles. and l> Give one dose of paracetamol In clinic for high fever (temp. 38.S"C or above) +MALARIA +now or within the last 3 Are they deep and • NO other cause :, Advise mother when to return immediately months: extensive? of fever l> Followup in 2 days +l> If fever is present everyday for more than 7 days, refer for assessment +• Look for pus draining from the eye +• Look for clouding of the cornea +• Runny nose l> Give one dose of paracetamol in clinic for high fever (temp.38.S"C or +FEVER: +PRESENT or +above) +• Measles PRESENT MALARIA .. Advise mother when to return immediately +or UNLIKELY .. Followup in 2 days +• Other cause of ;. If fever 1s present everyday for more than 7 days, refer for assessment fever PRESENT"* + +• Any general danger SEVERE .. Give first dose of vitamin A +sign.or COMPLICATED J> Give first dose of injectable chloramphenlcol (If not possible give oral +WMEA� +Now or within +last 3 months, +Classify +• Clouding of cornea. MEASLES• .. amoxlcl/1/n) +or ;-ff clouding of the cea or pus draining rom the eye, apply tetracycline eye +• Deep or extensive ointment +mouth ulcers l> Refer URGENTLY to hospital +• Pus draining from MEASLES WITH .. Give first dose of vitamin A +the eye.or EYE OR MOUTH .. If pus draining from the eye, treat eye infection with tetracycline eye ointment +• Mouth ulcers COMPLICATIONS ... .. If mouth ulcers. treat with gentian violet .. Followup in 2 days + +Measles now or MEASLES Give first dose of vitamin A within the last 3 +months +I + +· This cut off 1s for axillary temperatures. rectal temperature cutoff 1s approximately O. s·c higher +I +I +1 '"* Other causes of fever include cough or cold. pneumonia, diarrhea, dysentery and skin infections 1 +*/f referral +is +not possible, see the section Where Referral Is Not Possible in the module +*"·Other important complications of measles-pneumonia, stridor, diarrhea, ear infection, and malnutrition-are classfied in other tables Treat the Child + +Contd. + + + + + + +lo +al +Q. s: :, \i +I» +(0 I) +3 += +- + +I) +a I) +z +0 +ll += +n +:, + +ll Q. +;: :r +i: +g +- +5' + +Q. + +3: +II + + + + + + + + + +Chart 30.2 (Contd.) + +Does the child have an ear problem? +Tender swelling behind the ear +IFYES, ASK: LOOK AND FEEL: Classify "" +I +• Is there ear pain? • Look for pus draining from the ear EAR PROBLEM +I +• Is there ear discharge? • Feel for tender swelling behind the ear +If yes, for how long? • Pus is seen draining from the ear and discharge is reported for less than 14 days, or +• Ear pain + +Pus is seen draining from the ear and discharge is reported for 14 days or more + +• No ear pain, and +• No pus seen draining from the ear + + + + + + + + + +MAST OIDmS + + + + +ACUTE EAR INFECTION + + +CHRONIC EAR INFECTION + + +NOEAR INFECTION + + + + + + + + +, Give first dose of Injectable chloramphenlcol (If not possible give oral amoxyclllin) +, Give first dose of paracetamol for pain +,, Reer URGENn y to hospital' + +,Give Amoxicillin for S days .. Give paracetamol for pain +, Dry the ear by wicking i- Followup in 5 days + +;> Dry the ear by wicking +), Topical ciprofloxacin ear drops for 2 weeks , Followup in 5 days + + +No additional treatment + +m +ll += +ll I) +:I +ll +'C +0. +- +I) +ii' +:!. +0 +ll + + + + +#If referral is not possible, see the section Where Referral Is Not Possible in the module Treat the Child + + + +Contd. + + + + + +THEN CHECK FOR MALNUTRITION +Classify LOOK AND FEEL: NUTRITIONAL +STATUS + +• Look for visible severe wasting + +• Look for oedema of both feet + +Chart 30.2 (Contd.) + + +• Visible severe wasting, or • Oedema of both feet +> + + +Very low weight for age + + + + +SEVERE ;> Give single dose of vitamin A +MALNUTRITION ;>Prevent low blood sugar +,. Refer URGENn y to hospital' +;> While reral is being organized, warm the ch/Id .. Keep the ch/Id warm on the way to hospital + +VERY "Assess and counsel for feeding +LOW WEIGHT -If feeding problem, followup in 5 days ,Advise mother when to return immediately +,. Follow up in 30 days + + + +• Determine weight for age Not very low weight for age and no other signs of malnutrition + + +NOT VERY LOW WEIGHT + + +>If child is less than 2 yr old, assess the child's feeding +and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart +- If feeding problem, follow up in 5 days >Advise mother when to return immediately + + + + +THEN CHECK FOR ANEMIA +LOOK: Classify Severe palmar pallor SEVERE ANEMIA , Refer URGENTLY to hospital' +• Look for palmar pallor. Is it: +ANEMIA +- Severe palmar pallor? Some palmar pallor , Give iron folic acid therapy for 14 days +- Some palmar pallor? ;.Assess the child's feeding and counsel the mother on feeding according to the +FOOD box on the COUNSEL THE MOTHER chart - If feeding problem, followup in 5 days +ANEMIA +,. Advise mother when to return immediately , Follow up in 14 days +No palmar pallor I NO ANEMIA ;. Give prophylactic iron folic acid if child 6 mo or older + +THEN CHECK THE CHILD'S IMMUNIZATION *, PROPHYLACTIC VITAMIN A & IRON-FOLIC ACID SUPPLEMENTATION STATUS + +AGE VACCINE PROPHYLACTIC VITAMIN A PROPHYLACTIC IFA +Birth BCG + OPV-0 Give a single dose of vitamin A: +6weeks DPT-1 + OPV-1 (+ HepB-1..) 100,000 JU at 9 mo with measles immunization Give 20 mg elemental iron +100 mcg folic acid (one tablet of Pediatric 10weeks DPT-2 + OPV-2 (+ HepB-2'') 200,000 IU at 1�18 mo with DPT Booster IFA or 5 ml of IFA syrup or 1 ml of IFA drops) for a total of 100 days in a +IMMUNIZATION +SCHEDULE: +14 weeks DPT-3 + OPV-3 (+ HepB-3 ..) 200,000 IU at 24 mo and every 6 mo tiff year after the child has recovered from acute illness if: +9 mo Measles 60mo of age ;> The child 6mo of age or older. and +16-18 mo DPT Booster + OPV >Has not received Pediatric IFA tablet/syrup/drops for 100 days in last +60mo DT one year + +• A child who needs to be immunized should be advised to go for immunization the day vaccines are available at AWISC/PHC *-· Hepatitis B to be given wherever included in the immunization schedule + +ASSESS OTHER PROBLEMS + +:, +cc +(D +il (D +C. +s: :, +I» +I» +cc +(D +3 +:, +- +0 +z +0 +:, + +(D +.. (D + +I» +S' +I» + +:, +C. +") +t' +C: +t' +0 +0 +C. + +(D +:, +/1 +/1 + + + +MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments +Exception: Rehydration of the child according to Plan C may resolve danger signs so that referral is no longer needed + + +'If referral is not possible ,see the section Where Referral Is Not Possible in the module Treat the Child +_ E__s_e_s n.P.ti.ed al_ ----------------------------- +_i_tn·.ac. +s +-- +_ + + +breathing can be classified into one of the three categories. A child with general danger sign or chest indrawing or stri­ der is classified as severe pneumonia or very severe disease and merits urgent referral to the hospital. A sick child with cough who has fast breathing is classified as pneumonia and his treatment initiated in clinic with oral antimicrobials. A child with cough with none of these signs is classified as cough and cold and given home remedies to soothe throat and counseled for home care. +A child with cough or cold normally improves in one or two weeks. However, a child with chronic cough (more than 30 days) needs to be further assessed (and, if needed, referred) to exclude tuberculosis,asthma,whooping cough or any other problem). +Diarhea A child with diarrhea passes stools with more water than normal. A child with diarrhea may have (i) acute watery diarrhea (including cholera); (ii) dysentery (bloody diarrhea); or (iii) persistent diarrhea ( diarrhea that lasts 14 days or more). +Most diarrheal episodes are caused by agents for which antimicrobials are not effective and therefore antibiotics should not be used routinely for treatment of diarrhea. Antidiarrheal drugs do not provide practical benefits for children with acute diarrhea, and some may have dan­ gerous side effects. Therefore these drugs should never be given to children. +Clinical assessment and classification. All children with diarrhea should be assessed for dehydration based on the following clinical signs: child's general condition (lethargic or unconscious or restless/irritable); sunken eyes; child's reaction when offered to drink (not able to drink or drinking poorly or drinking eagerly/thirsty or drinking normally) and elasticity of skin (skin pinch goes back very slowly, slowly or immediately). In addition a child with diarrhea should be asked how long the child has had diarrhea and if there is blood in the stool. This will allow identification of children with persistent diarrhea and dysentery. +Children with severe dehydration require immediate IV infusion according to WHO treatment guidelines described in plan C. Children with some dehydration require active oral treatment with ORS as per plan B. Patients with diarrhea and no dehydration are advised to give more fluid than usual to prevent dehydration according to WHO treatment plan A. +All children with persistent diarrhea are classified based on presence or absence of dehydration. Children with per­ sistent diarrhea and dehydration are classified as severe persistent diarrhea and need to be referred to hospital after treatment of dehydration. Children with persistent diar­ rhea and no dehydration can be safely managed on out­ patient basis with appropriate feeding. Children with dysentery are given effective antibiotics for shigellosis. +Fever Fever is a very common condition and is often the main reason for bringing children to the health center. It + +may be caused by minor infections, but may also be the most obvious sign of a life-threatening illness, e.g. P. falciparum malaria or meningitis. When diagnostic capacity is limited, it is important first to identify those children who need urgent referral with appropriate prereferral treatment (antimalarial or antibacterial). All sick children should be assessed for fever if it is reported by mother or fever is present on examination. +Clinical assessment and classfication. In endemic areas the risk of malaria transmission is defined by areas of high and low malaria risk in the country. National Anti Malaria Program (NAMP) has defined areas depending on malaria risk. A child presenting with fever is assessed and classified depending on risk of malaria. History of duration of fever is important in evaluating fever. If fever has persisted daily for more than seven days the child needs to be referred to hospital for assessment and diagnostic tests. The other signs looked for in a child with fever include general danger signs (assessedearlier)andsignsofmeningitis,e.g.bulgingfontanel and stiffneck. Besides these,signs of measles and runny nose are also looked for. +If the child has measles currently or within the last three months, he should be assessed for possible complications. Some complications of measles are assessed as main symptoms, e.g. cough/difficult breathing, diarrhea and ear infections. Clouding of cornea and mouth ulcers are asses­ sed along with measles. Clouding of cornea is a dangerous eye complication. If not treated, cornea can ulcerate and cause blindness. An infant with corneal clouding needs urgent treatment with vitamin A. +Before classifying fever, one should check for other obvious causes of fever. +Children with fever are classified based on the presence of any of the general danger signs,stiff neck,level of malaria risk in the area and presence/absence of symptoms like runny nose, measles or clinical signs of other possible infection. In high malaria risk area all children with fever need to get antimalarial treatment as per NAMP guidelines. In areas with low malaria risk children with fever with no other obvious cause are classified as malaria and should be evaluated with blood smear and treated with oral anti­ malarial drugs (chloroquine). In low malaria risk area children with fever with another cause of fever (e.g. cough and cold or ear infection or diarrhea) are classified as fever, malaria unlikely and given symptomatic treatment for fever. Since the malaria risk may change with time malaria is treated as per national guidelines. +Ear problems A child with an ear problem may have otitis. It may be acute or chronic infection. If the infection is not treated, the ear drum may perforate. Ear infections are the main cause of deafness in low-income areas, which in-turn leads to learning problems. The middle ear infection can also spread from the ear and cause mastoiditis and/ or meningitis. The sick child is assessed for ear infection if any ear problem is reported. +Integrated Management of Neonatal and Childhood Illness + + + +Clinical assessment and classification. The mother is asked about history of ear pain and ear discharge or pus. The child is examined for tender swelling behind the ear. Based on these clinical findings a child can be classified as mastoiditis, acute ear infection, chronic ear infection or no ear infection. Children with mastoiditis are classified as severe illness and referred urgently to hospital. Children with acute ear infection are given oral antibiotics and those with chronic ear infection are advised to keep the ear dry by wicking. + +Checking for Ma/nutrition +After assessing for general danger signs and the four main symptoms, all children should be assessed for malnutrition. There are two main reasons for routine assessment of nutri­ tional status in sick children: (i) to identify children with severe malnutrition who are at increased risk of mortality and need urgent referral to provide active treatment; and (ii) to identify children with suboptimal nutritional status resulting from ongoing deficits in dietary intake plus repeated episodes of infection and who may benefit from nutritional counseling. + +Clinical Assessment and Classification +Visible severe wasting. This is defined as severe wasting of the shoulders, arms, buttocks, and legs, with ribs easily seen, and indicates presence of marasmus. When wasting is extreme, there are many-folds of skin on the buttocks and thigh. It looks as if the child is wearing baggy pants. The face of a child with visible severe wasting may still look normal. The child's abdomen may be large or distended. +Edema of both feet. The presence of edema in both feet may signal kwashiorkor. +Weightjor-age. Plotting weight for age in the growth chart, based on reference population, helps to identify children with low (Z score less than -2) or very low (Z score less than -3) weight for age, those who are at increased risk of infection and poor growth and development. +Classification of nutritional status. Using a combination of the simple clinical signs above, children can be classified as severe malnutrition (visible wasting with or without edema), very low weight or not very low weight. + +Checking for Anemia +All children should also be assessed for anemia. The most common cause of anemia in young children in developing countries is nutritional or because of parasitic or helminthic infections. +Clinical assessment and classfication: Palmar pallor can help to identify sick children with severe anemia. Wherever feasible, diagnosis of anemia can be supported by using a simple laboratory test for hemoglobin estimation. For clinical assessment of anemia the color of the child's palm is compared with examiner's own palm. If the skin of the child's palm is pale, the child has some palmar pallor. If the + + +skin of the palm is very pale or so pale that it looks white, the child has severe pa/mar pallor. Based on palmar pallor it is classified as severe anemia, anemia or no anemia. + +Assessing the Child's Feeding +All children less than 2-yr-old and all children classified as anemia or very low weight need to be assessed for feeding even if they have a normal Z score. Feeding assessment includes questioning the mother or caretaker about feeding history. The mother or caretaker should be given appro­ priate advice to help overcome any feeding problems found. +To assess feeding, ask the mother: does she breastfeed her child (how many times during the day and night), does the child take any other food or fluids (what food or fluids, how many times a day, how the child is fed, how large are the servings, does the child receive his own serving, who feeds the child) and during the illness, has the child's feeding changed (if yes, how?) +Identify feeding problems When counseling a mother about feeding, one should use good communication skills. It is important to complete the assessment of feeding by referring to age appropriate feeding recommendations and identify all the feeding problems before giving advice. In addition to differences from the feeding recommendations, some other problems may become apparent from the mother's answers. Other common feeding problems are: Dficulty breastfeeding, use offeeding bottle, lack of active feeding and not feeding well during illness. IMNCI guidelines recommend locally acceptable, available and affordable foods for feeding a child during sickness and health. A sample of such recommendations is given in the IMNCI chart which needs to be adapted to local conditions. + +Checking Immunization, Vitamin A and Folic Acid Supplementation Status +The immunization status of every sick child brought to a health facility should be checked. Children who are well enough to be sent home can be immunized. +After checking immunization status, determine if the child needs vitamin A supplementation and/or pro­ phylactic iron folic acid supplementation. + +Assessing other Problems +The IMNCI clinical guidelines focus on five main symp­ toms. In addition, the assessment steps within each main symptom take into account several other common prob­ lems. For example, conditions such as meningitis, sepsis, tuberculosis, conjunctivitis, and different causes of fever such as ear infection and sore throat are routinely assessed within the IMNCI case management process. If the guide­ lines are correctly applied, children with these conditions will receive presumptive treatment or urgent referral. Nevertheless, health care providers still need to consider other causes of severe or acute illness. +--Ess •nt a .P.d••. r.ic -------------------------------- +• +• +• +e +• +i +• +• +I +a +t +• +s +e +i + + +Identify Treatment and Treat +All the treatments required are listed in the Identify Treatment column of the Assess and Classify the Sick Child Age 2 Months up to 5 Years (Chart 30.2). All sick children with a severe classification (pink) are referred to a hospital as soon as assessment is completed and necessary pre­ referral treatment is administered. If a child only has severe dehydration and no other severe classification, and IV infusion is available in the outpatient clinic, an attempt should be made to rehydrate the sick child. The principles of referral of a sick child are similar to those described for a sick young infant. + +Referral of Children Age 2 Months up to 5 Years +Possible prereferral treatment(s) includes: +• For convulsions diazeparn IV or rectally. If convulsions continue after 10 min give a second dose. +• First dose of appropriate intramuscular antibiotic­ +chloramphenicol or ampicillin + gentamicin or ceftria­ xone (for severe pneumonia or severe disease; very severe febrile disease; severe complicated measles; mastoiditis). Give oral antibiotic if injectable antibiotics are not available. +• First dose of quinine (for severe malaria) as per national guidelines. +• Vitamin A (persistent diarrhea, measles, severe malnutrition). +• Prevention of hypoglycemia with breast milk or sugar water. +• Oral antimalarials as per guidelines. +• Paracetamol for high fever (38.5°C or above) or pain. +• Tetracycline eye ointment (if clouding of the cornea or pus draining from eye). +• Frequent sips of ORS solution on the way to the hospital in sick children with diarrhea. +If a child does not need urgent referral, check to see if the child needs nonurgent referral for further assessment; +for example, for a cough that has lasted more than 30 days, or for fever that has lasted seven days or more. These referrals are not as urgent, and other necessary treatments may be done before transporting for referral. + +Treatment in Outpatient Clinics and at Home +Identify the treatment associated with each nonreferral classification (yellow and green) in the IMNCI chart. Treatment uses a minimum of affordable essential drugs. Following guidelines for treatment need to be followed: • Counseling a mother/ caretaker for looking after the +child at home is very important. Good communication skills based on principles of APAC are helpful for effective counseling. +• Give appropriate treatment and advice for 'yellow' and 'green' classifications as detailed in Table 30.2. + + +Table 30.2: Treatment guidelines for managing sick child In outpatients and at home +Pneumonia, acute ear infection: Give the first dose of the antibiotics in the clinic and teach the mother how to give oral drugs, cotrimoxazole +Dysentery: Give the first dose of the antibiotic in the clinic and teach the mother how to give oral drug, ciprofloxicin for 3 days +Cholera: In areas where cholera can not be excluded, children more than 2-year-old with severe dehydration should be given a single dose of doxycycline +Dehydration and persistent diarrhea: Treat 'some' and 'no' dehydration and persistent diarrhea as per standard WHO guidelines +Persistent diarrhea and severe malnutrition, give single dose of vitamin A in the clinic +Measles, give two doses (first dose in clinic and give mother one dose to give at home the next day) +Malaria: Treat as per recommendations Anemia: Give iron folic acid for 14 days +Cough and cold: If the child is 6 months or older use safe home remedies (continue breastfeeding, use honey, tulsi, ginger and other safe local home remedies) +Local infection: Teach the mother or caretaker how to treat the infection at home. Instructions may be given about how to: Treat eye infection with tetracycline eye ointment; dry the ear by wicking to treat ear infection; treat mouth ulcers with gentian violet +For acute diarrhea, persistent diarrhea and dysentery, give zinc (10-20 mg) supplements for 14 days + + +Counseling a Mother or Caretaker +A child who is seen at the clinic needs to continue treatment, feeding and fluids at home. The child's mother or caretaker also needs to recognize when the child is not improving, or is becoming sicker. The success of home treatment depends on how well the mother or caretaker knows how to give treatment, understands its importance and knows when to return to a health care provider. Some advice is simple; other advice requires teaching the mother or caretaker how to do a task. When you teach a mother how to treat a child, use three basic teaching steps: give information; show an example; let her practice. +• Advise to continue feeding and increase fluids during illness +• Teach how to give oral drugs or to treat local infection; • Counsel to solve feeding problems (if any) +• Advise when to return (Table 30.3). Every mother or caretaker who is taking a sick child home needs to be advised about when to return to a health facility. The health care provider should (i) teach signs that mean to return immediately for further care, (ii) advise when to return for a followup visit, and (iii) schedule the next well-child or immunization visit. +Integrated Management of Neonatal and Childhood Illness +- ---- - + + +Table 30.3: Counsel mother when to return +Mother should report immediately if she notices following symptoms +Young infant Sick child (age 0-2 mo) (2 mo-5 yrs) +Breastfeeding or drinking Any child +poorly Not able to drink or Becomes sicker breastfeed Develops fever or cold to touch Becomes sicker +Develops fever Fast/ difficult breathing Child with cough and Blood in stools (if infant cold +has diarrhea) Develop fast/ difficult Yellow palms and soles breathing +(if jaundiced) Child with diarrhea Has blood in stool Drinking poorly + +Mother should bring infant for followup visit • +Mother should come for scheduled immunization visit •see section on identify treatment + + +REVISION IN IMNCI GUIDELINES +IMNCI strategy recommends adaptation of clinical and management guidelines based on the local epidemiologic + +scenario and management guidelines, which are evidence­ based, pertain to majority of common childhood illnesses, are locally relevant and feasible. Evaluation and providing justification for revision of these guidelines is a continuous process. With the availability of more epidemiological data on common childhood illnesses in India, there is a possibility of future inclusion of conditions like HIV/ AIDS, dengue fever and asthma at national or state level revision of IMNCI guidelines. + +Suggested Reading +Gove S. For the WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bull WHO 1997;75:7-24 +Integrated Management of Neonatal and Childhood Illness. Training Modules for Physicians. Ministry of Health and Family Welfare, Govt. of India, 2003 +Murray CJL, Lopez AD. The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. In: Global Burden of Disease and Injury Series (vol. I), Cambridge, MA, Harvard School of Public Health, 1996 +World Health Organization. Integrated Management of Childhood Illness. WHO/CHD/97.3.A -3.G, WHO, Geneva, 1997 +World Health Organization. Integrated Management of the Sick Child. Bull WHO 1995; 73:735-40 +World Health Organization. Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for care at the first-referral level in developing countries. WHO, Geneva, 2000 + +Rights of Children + + + + + + + +Rajeev Seth + + + + + + +The Constitution of India guarantees equality before the law to all citizens and pledges special protection for children. In 1992, India accepted the obligations of the UN Convention on the Rights of the Child (CRC). In the last two decades, the government has taken several steps towards publicly advancing children's rights. These include the formation of the National Commission for Protection of Child Rights (2005), a National Plan of Action for Children (2005) and advancing various legislations such as Right to Education (2009) to protect, promote and defend child rights in the country. Physicians need to be familiar with child rights in order to ensure advocacy for children and their families. + +United Nations Convention on the Rights of the Child +The United Nations Convention on the Rights of the Child (UN CRC) is the first legally binding international instru­ ment to incorporate civil, cultural, economic, political and social rights for children. It sets out these rights in 54 articles and two optional protocols. Table 31.1 provides articles of UN CRC that apply to child health. There is sufficient evidence globally to acknowledge that the UN CRC has influenced childrens access to health and well-being. +Every pediatrician can, and should have, adequate knowledge of the rights of children in domains of child survival, identity, development, protection and parti­ cipation. They should understand the broad social deter­ minants of child health, become trained in the use of CRC, align themselves with like-minded organizations in efforts at advocacy, and lobby their local, state and national elected representatives to advance child rights. + +Promotion and Protection of Child Rights in India +In 2006, the Government of India upgraded to an independent status the Ministry of Women and Child Development, in order to focus on issues concerning the welfare of women and children. The National Commission + + +Table 31.1: rticles of the UN Convention on the Rights of the Child that apply to child health +Article Purpose +Article 2 Protection from discrimination +Article 3 Best interests of the child are a primary consi­ deration: The institutions, services and facilities responsible for the care or protection of children shall conform to the standards established by competent authorities +Article 5 Parents are responsible for ensuring that child rights are protected +Article 6 Right to survival and development +Article 9 Right of the child who is separated from one or both parents to maintain personal relations and direct contact with both parents on a regular basis +Article 12 Right of a child to express his/her views, consi­ dering the maturity of the child +Article 14 Freedom of expression including seeking, receiving and imparting information +Article 16 Protection of privacy +Article 17 Access to information from mass media, with protection from material injurious to the child's well-being +Article 18 Assistance to parents with child rearing responsi­ bilities +Article 19 Protection from physical and mental violence, abuse or neglect +Article 20 Special protection to children deprived of their families +Article 22 Protection of children seeking refugee status Article 23 Rights of disabled children to special care Article 24 Right to health and access to health care Article 27 Right to an adequate standard of living Article 28 Right to education +Article 30 Right to the child's own culture and religion Article 31 Participation in leisure and play +Article 34 Protection from sexual exploitation + + +768 + +------- +----- +h h +l +-------- _i r +n +--------- -R-ig__ts_o_t_c__d_e__� + +or Protection of Child Rights, constituted in 2007, provides 'or setting up of state level Commissions meant for protection and promotion of child rights in the country. Besides the institutional, administrative and legislative framework, India has a strong presence of non-Govenmental organizations (NGOs) that, along with the media, act as +watchdogs to protect human and child rights. + +Measures for Implementation +Several policies, laws and programs have been introduced to implement the national commitment to child rights. These include: +National Policy for Children (1974). This policy declared children as being a supreme national asset. +National Charter for Children (2003). The charter emphasizes the Government's commitment to rights of children, while enumerating children's duties towards their families, society and nation. +National Plan of Action for Children (2005). This plan commits to ensuring rights of all children by creating an enabling environment for their survival, growth, development and protection. +National Policy for Persons with Disabilities (2006). The policy recognizes that a majority of persons with disabilities can lead a better quality of life if they have access to equal opportunities and effective rehabilitation measures. +Policy Framework for Children with AIDS in India (2007). This policy seeks to address the needs of children affected by HIV /AIDS, by integrating services for them within the existing development and poverty reduction programs. +National Rehabilitation and Resettlement Policy (2007). Under this policy, no project involving displacement of families can be undertaken without a detailed assessment of social impact on the lives of children. +National Urban Housing and Habitat Policy (2007). The policy seeks to promote sustainable development of habitat and services at affordable prices in the country and thereby provide shelter to children from disadvantaged families. + +National Legislation +The legislative framework for children's rights is being strengthened by the formulations of new laws and amendments in old laws. These include the Food Security bill (2011), Right to Free and Compulsory Education Act (2009), Prohibition of Child Marriage Act (2006), the Commissions for Protection of Child Rights Act (2005), Amendments to Juvenile Justice (Care and Protection of Children) Act (2006), Right to Information (2005), the Goa Children (amendment) Act {2005), the Child Labor (Prohibition and Regulation) Act (1986) and Information and Technology (amendment) Act {2008). Two noti­ fications in 2006 and 2008 expanded the list of banned and hazardous processes and occupations. New legislations + +include the Bill for Prevention of Offences against the Child and the HIV/AIDS bill. + +National Programs +The Government of India is implementing several pro­ grams on social inclusion, gender sensitivity, child rights, participation and protection. These programs include: Integrated Child Development Services (ICDS), Kishori Shakti Yojana and Nutrition Program for Adolescent Girls, Rajiv Gandhi Creche Scheme for children of working mothers, Sislzu Grah (scheme for assistance to homes for children to promote in-country adoption), Dhanalakshmi (conditional cash transfer schemes for the girl child), Program for Juvenile Justice, Child Line (outreach services for children in need of care and protection through 24 hr toll free number 1098), Integrated Child Protection Scheme, Integrated Program for Street Children, Ujjawala (scheme for prevention of trafficking and rescue, rehabilitation, reintegration and repatriation), Sarva Shiksha Abhiyan (scheme to address educational needs of 6 to 14-yr-old and bridge social, gender and regional gaps with active community participation), National Program for Edu­ cation of Girls at elementary level (Kasturba Gandhi Balika Vidyalaya), National Rural Health Mission, Mid-day Meal Program, Jawaharlal Nehru National Urban Renewal Mission, Universal Immunization Program (UIP) and Integrated Management of Neonatal and Childhood Illness (IMNCI). + +Role of Pediatricians in Realizing Child Rights +The most basic and crucial child rights are survival and early childhood care, including health care, nutrition, growth, development and education. Prevention of neglect and protection from exploitation (street children, child +labor, trafficking) are complex issues. Parents are often illiterate and ignorant of the rights of their children; awareness of these rights is essential so that they can fight to obtain them. +Pediatricians should join hands with committed groups of multidisciplinary child health professionals, nurses, teachers, social workers, psychologist, lawyers, police, judiciary, child rights activists and community leaders in order to work together and monitor governmental efforts in promotion and protection of various child rights. They should be able to gather and collate available indicators of national child health, address key issues and concerns and facilitate children's participation in projects and policy development. Pediatricians should collaborate with national and international NGOs to initiate advocacy campaigns and media releases in order to change policy, legislations and practice in accordance with the UN CRC. + +CHILD ABUSE AND NEGLECT +The term child abuse has different connotations in different cultural milieu and socioeconomic situations. The World Health Organization (WHO) defines child abuse or +--E.s +.. .. +_____ +.s ______ +____ +s.e.n ti.a_1_P_e_d_ia_t_r1c _____________ _ + + +maltreatment as forms of physical and/ or emotional ill­ treatment, sexual abuse, neglect or negligent treatment or commercial exploitation that results in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power. Major types of child abuse by caregiver or other adults include: +Physical abuse. Acts of commission by a caregiver that cause actual physical harm or have the potential for harm. +Sexual abuse. Those acts where a caregiver uses a child for sexual gratification. +Emotional abuse. The failure of a caregiver to provide an appropriate and supportive environment, including acts that have an adverse effect on the emotional health and development of children. +Neglect. The failure of a parent or guardian to provide for the development of the child, where he/ she is in a position to do so, in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions. Neglect is thus distinguished from circumstances of poverty, in that neglect can occur only in cases where reasonable resources are available to the caregiver. + +Manifestations +Injuries inflicted by a caregiver on a child can take many forms. Patterns of injury to the skin are noted. Skeletal manifestations of abuse include multiple fractures at different stages of healing. Death in abused children is most often the consequence of a head injury or injury to internal organs. About one-third of severely shaken infants die and the majority of survivors suffer from longterm consequen­ ces such as mental retardation, cerebral palsy or blindness. Children who have been sexually abused may exhibit symptoms of infection, genital injury, abdominal pain, constipation, chronic or recurrent urinary tract infections or behavioral problems. Many children will disclose abuse to caregivers or others spontaneously, although there may be additional direct physical or behavioral signs. Emotional and psychological abuse has received less attention globally due to cultural variations in different countries. Corporal punishment of children, in the form of slapping, punching, kicking or beating, is a concern in schools and other institutions. Child neglect can manifest as failure to thrive, failure to seek basic health care, immunization and depri­ vation of education and basic nutrition needs. A neglected child is exposed to environmental hazards, substance abuse, inadequate supervision, poor hygiene and abandonment. + +Strategies to Reduce Child Abuse and Neglect +Preventing child abuse and neglect should be part of national agenda. In India, abuse and neglect of children is a major social and public health problem, especially among socially marginalized and economically backward groups, + +such as children in urban slums, street and work children and children of construction workers. While cl labor cannot be abolished in the presence of abject pove; the Government should ensure that working children, not exploited. Protection of children against all forms abuse and exploitation is a basic child right. The emplo) must provide for health care for children and ensure th they get time for education. +A comprehensive approach to child protection services 1 rural areas should involve the established system c Panchayati Raj. The panchayat officials should be responsibl for ensuring basic education, nutrition, health care am sanitation for every child in the village. It should be bindinf on the panchayat to ensure that each child attends school anci is protected from agrarian and allied rural occupations as a part of family or individual child labor. +Pediatricians have a significant role in recognizing, responding to and reporting child abuse. They are often the first point of contact of a child with abuse and the best advocates for protection of their rights. While Indian laws do not make it mandatory to report child abuse and neglect, pediatricians should seek assistance from Special Juvenile Police units, Child Welfare Committees, Child Line (an emergency toll-free phone service for children in distress), National and state Commissions for Protection of Child Rights (NCPCR) and NGOs, and direct families to these services. Pediatricians can work with the community, NGOs and governmental administrators to reach out to neglected, deprived and abused children. + +Suggested Reading +Aggarwal K, Dalwai S, GaJagali P, Mishra D, Prasad C, Thadhani A, et al. Recommendations on recognition and response to child abuse and neglect in the Indian setting. Jndian Pediatr 2010;47:49�504 +Convention on the Rights of the Child, available from www.unicef. org/crc +Delhj Declaration. http: www.inruanpediatrics.net/delhi declaration 2011.pdf +Srivastava RN. Child abuse and neglect: Asia Pacific Conference and the Delhi Declaration. Jndian Pediatrics 2011;49:ll-2 +Study on Child Abuse: India (2007). Ministry of Women and Child Development, Government of Jndia, available from www.wcd.nic.in/ childabuse.pdf +Thjrd and Fourth combined periodic report on the Convention on the Rights of the Child 2011, available from www.wcd.nic.in + +ADOPTION +Adoption is an important option for the rehabilitation of destitute and abandoned children or those who cannot be brought up by their parents due to social reasons. Medical practitioners play a vital role in influencing health and social decisions of their adoptive patients and should work closely with counselors and health professionals. + +Legal Aspects +'Right to a family' is proposed as a fundamental right by the United Nations. Adoption agencies should ensure that these rights are protected. In India, only agencies recognized by +--------------------------------R-i_g_h_ts_o_r__e_ +n +f +_c__h +i +ld + + +the Govenment can deal with adoption placement. Private adoptions, including direct placement by hospitals, maternity and nursing homes, are illegal. Prior to 2000, adoption was allowed to Hindus under the Hindu Adoption and Maintenance Act; other religious groups were governed by the Guardianship and Wards Act. The Juvenile Justice (Care and Protection of Children) Act, passed by the parliament in 2000, enables citizens of all religions the freedom to adopt a minor child, irrespective whether he/she is a single parent. Such adoptive parents may adopt a child of the same sex, irrespective of the number of living biological sons or daughters. + +Procedure of Adoption +A child, who has been relinquished by his/her biological parents or found abandoned, must first be presented to the Child Welfare Committee. Under the current law, this committee has the sole authority to declare the child available for adoption. After due investigations, the committee declares the child as destitute and available for adoption. In case the biological parents want to relinquish a child, they have to execute a document in favor of the adoption agency, witnessed by any authority of the hospital and a relative. A waiting period of two months is given to biological parents to reconsider the decision, following which the child is free for adoption. + +Prospective Adoptive Parents +A child can be adopted by a married couple with infertility or those voluntarily opting for adoption. Even single persons are eligible to adopt. Couples who have taken a decision to adopt should go to an agency licensed by the state government and the Central Adoption Resource Authority, an autonomous body in the Ministry of Women and Child Development. Only recognized placement agencies can process the application of abandoned Indian children for in-country and inter-country adoptions. + +Applications for inter-country adoption of a child born in India should be forwarded by an accredited agency of the country of the adoptive parents, to an agency in India, along with all documents to the Central Adoption Resource Authority. +A social worker from the adoption agency performs pre­ adoption counseling, which includes providing guidelines and support to pre-adoptive parents, helping them make informed decisions. A home study is conducted by a pro­ fessional social worker. Additionally, parents are required to submit a document regarding their health and financial status. Once the application is approved, a suitable child is shown to them. After they accept the child, placement is legalized. The placement is followed up to a period of 3 yr or such time until legal adoption is complete. The adoptive parents are assured confidentiality and provided support as needed. + +Role of the Pediatrician +Families often take pediatricians into confidence and seek their advice. Additionally, babies in placement agencies are usually taken for a second opinion to a pediatrician. Pedia­ tricians can counsel and teach families about the process of adoption. A supporting and understanding attitude encourages adoptive parents to overcome their fears. The physician should examine the child carefully and explain to the adoptive parents the diagnoses, if any, and their prognosis. They should ensure that all essential tests (such as HIV, hepatitis B) with a window period are repeated at 3 and 6 months before placement. Parents who wish to relinquish their children due to any reason should be counseled about the correct procedure so as to ensure that children are not left in public places or unhealthy surround­ ings, which may be unsafe and traumatizing. + +Suggested Reading +Central Adoption Resource Agency; www.adoptionindia.nic.in + +Index + + + + +Abdominal pain 286 chronic 289 common causes 287 red flag signs 290 +related to functional gastrointestinal disorders 290 +Abdominal tuberculosis 305 Accredited social health activist +(ASHA) 2, 4 Accidents 696 +Acid-base disorders 83 algorithm 83 +Acid-base equilibrium +compensation for primary disorders 83 regulation 83, 84 +renal regulation of 84 Acne vulgaris 682 Acute diarrhea +assessment 292, 293 causes 291 +clinical findings 291 dehydration 292 drug therapy 296 +laboratory investigations 292 management 293, 295 +oral rehydration solution 294 prevention 296 +treatment 294, 295 +zinc supplementation 295 +Acute disseminated encephalomyelitis 569 Acute flaccid paralysis 592 +differential diagnosis of 592 surveillance 592 +Acute glomerulonephritis 474 etiology 474 +indications for renal biopsy 47 4 Acute hemiplegia of childhood 577 +causes 577 +clinical features 577 management 578 +Acute kidney croup injury 487 clinical features 487 complications 489 +definition 487 dialysis 491 etiology 487 evaluation 487, 492 investigations 488 management 488 newborn 491 staging 487 +Acute laryngotracheobronchitis, see Croup Acute liver failure, see Liver failure +Acute lyrnphoblastic leukemia 599, 600 chemotherapy protocol for 603 clinical presentation 601 +differential diagnosis 601 Down syndrome 601, 605 evaluation 602 management 602,603,604 + +prognostic factors 600 risk factors 599 +treatment after relapse 604 Acute myeloid leukemia 605 +classification 606 clinical features 606 +genetic abnormalities 605 treatment 606 +Acute promyelocytic leukemia 607 Acute otitis media 359 +etiology 359 treatment 359 with effusion 360 +Acute nephritic syndrome,etiology of 474 Acute renal failure, see Acute kidney injury Acute respiratory distress syndrome 393 Acute respiratory tract infection (ARI) +control program 380 WHO classification 381 +Acute viral hepatitis, see Hepatitis Acyanotic congenital heart defects 413 Adenotonsillectomy 367 +ADHD, see Attention deficit hyperactivity disorder +Adolescence 63, 65 +attitude towards health 65 cognitive, social development 63 health problems 65, 66 immunization 69 +legal age 67 +transition to adult care 69 Adolescent +adolescent friendly health services 68, 69 contraception 67, 69 +Adoption 770 legal aspects 770 procedure 771 +Adrenal insufficiency 523 Adrenocortical excess 523 Adrenoleukodystrophy, X-linked 664 AFP, see Acute flaccid paralysis +Age independent indices 97 Aldosterone excess 525 Alkaptonuria 653 +Allornmune thrombocytopenia, neonatal 352 +Alopecia areata 683 Alport syndrome 473 Amblyopia 669 Amebiasis 268 +clinical features 269 diagnosis 269 treatment 269 +Amebic meningoencephalitis 271 Aminoacidopathies 652 Analgesics 739, 740 +Anemia 330, 331 +approach to macrocytic 333 approach to microcytic 332 approach to normocytic 333 +773 + + +clinical features 331 evaluation 331 +Anganwadi worker 2, 4 Anion gap 84 +urinary 85 +Anomalous left coronary artery from pulmonary artery 448 +Anorectal malformation 177 Anorexia nervosa 57 +Antenatal hydronephrosis 507, 508 Anterior horn cells, disorder affecting 588 Anticonvulsants 554, 745 +for refractory status epilepticus 555 Antidotes 745 +administration of 700, 701 Antiphospholipid antibody +syndrome 629 Antitoxins 746 +Aortic regurgitation 441 clinical features 442 differential diagnosis 442 management 442 +Aortic stenosis 429 assessment of severity 430 clinical features 429 treatment 431 +Apgar score 126 Aplastic anemia 345 +congenital syndromes associated with 346 etiopathogenesis 345 +laboratory studies 346 treatment 347 +Apnea 125, 171 Appendicitis, acute 287 Arrhythmia 457, 458, 714 +diagnosis of tachyarrhytnia 458, 459 initial assessment 459 +irregular wide QRS tachycardia 461, 462 narrow QRS tachycardia 460, 462 narrow QRS tachycardia 459, 460 treatment for bradyarrhynias 459 +Arterial catheterization 731 Arthritis 624 +approach to diagnosis 624 classification 624 +reactive 624 septic 624 +synovial fluid characteristics 625 tubercular 624 +Ascites 318 causes 318 +investigation 318, 734 treatment 318 +Ascitic tap 734 Asphyxia 125, 166 +diagnosis and approach 167 multiorgan dysfunction 166 neuropathology 166 +post-resuscitation management 167 prognosis 168 +___ _s_s_e_n t,_·al_P_e_d_iat_rics _______________________________ +E +_ +_ +_ +_ +_ + +Aspergillosis 260 +Asthma, bronchial 382,389 classification of severity 387, 391 clinical features 383 +diagnosis 383,389 management 384,390,747 pathology 382,383 pharmacotherapy 385 +step wise treatment 386,387 Asymmetric tonic neck reflex 143 Ataxia-telangiectasia 186, 580,586 Ataxia 579 +acute cerebellar 579 causes 579 Friedreich 580 +Atopic dermatitis 680 Atrial septa! defect 413 +assessment of severity 414 complications 414 physiology 413 +treatment 414 +Attention deficit hyperactivity disorder 59 clinical features 59 +diagnosis 59 management 60 +Autistic disorder 61 +Autoimmune hemolytic anemia 340 clinical features 340 +cold reactive autoantibodies 340 management 340 +warm reactive autoantibodies 340 Autoimmune liver disease 321 Autosomal dominant disorders 641 Autosomal recessive disorders 641 + +Bacillus Calmette Guerin (BCG) 190 Bag and mask ventilation 129, 712 Baggy pants appearance 99 +Bangle test 97 +Barlow maneuver 141 Bartter syndrome 501 Basophilia 357 +BCG test 254 +Becker muscular dystrophy 595 Behavioral disorders 57 +Beh<;et disease 634 +Benign intracranial hypertension, see Pseudotumor cerebri +Biotin 120 +Birthmarks, vascular 679 Bladder catheterization 734 Bleeding 349 +clinical evaluation 349,351 differences between platelet and +coagulation disorders 350 laboratory investigations 350 +Block skills 51 +Blood component therapy 355 Blood gas analysis 374 +Body mass index (BMI) 13 for age 26,32-34 +Bone age 11 +Bone marrow aspiration, biopsy 736 Bone marrow failure,see Aplastic anemia Bone tumor 619 +Bradyarrhythmias,see Arrhythmia Brain abscess 573 + +Brain tumors 571,612,613 brainstem 571 +cerebellar 571 +clinical presentation 613 diagnosis 614 supratentorial 572 treatment 614 +Breast milk benefits of 150 +composition of 153 expressed 155 +Breastfeeding 90, 150,151, 154 drug therapy 180 physiology 151 +principles 90 problems in 154 technique of 153 +Breath holding spells 58 Bronchial asthma, see Asthma Bronchiectasis 392 Bronchiolitis 381 +causes 382 +clinical features 381 differential diagnosis 382 treatment 382 +Bronchodilators 386, 747 Bronchopulmonary dysplasia 171 Bronchoscopy 373 +Brucellosis 259 +Bruton agammaglobulinemia 186 Budd-Chiari syndrome 320 Bulimia 57 +Bullous impetigo 688 Bums 705 + +Calcium 79, 521 corrected 80 +disorders of metabolism 521 Calcitonin 79 +Calcium sensing receptor 79 Cancer survivorship 623 Candidiasis 366,694 +invasive 259 +Caput succedaneum 141 +Cardiac catheterization, diagnostic 409 Cardiomyopathy 447 +Cardiopulmonary resuscitation, drugs 714 Cardiovascular disease, preventing +adult 462 Carotenemia 111 Carrier screening 645 Cataract 670 +Catch-up diets 106 Catheterization of bladder 734 Celiac disease 301 +diagnosis 301 treatment 307 +Cellulitis 688 Cephalohematoma 141 Cerebral edema 547 Cerebral palsy 581 +cerebellar 582 diagnosis 582 etiopathogenesis 581 extrapyramidal 582 +hypotonic (atonic) 582 +management 583 + + +mixed 582 spastic 582 +Coarctation of aorta 431 clinical features 432 complications 432 hemodynamics 431 treatment 432 +Constrictive pericarditis, chronic 450 Corrected TGA 426 +Cyanosis and high pulmonary flow 428 Cyanotic heart disease 420 +with pulmonary arterial hypertension 428 Congenital heart disease, see also individual +defects 404, 409 acyanotic 413 +catheter-based interventions 410 catheter interventions for 410 complications of 410 +cyanosis and high pulmonary flow 428 cyanotic heart disease with pulmonary +arterial hypertension 428 cyanotic spells 411 +duct dependent lesions 405 Fallot (VSD-PS) physiology 404 hemodynamic classification 403 infective endocarditis in 411 Nadas' criteria 406 +natural history 411 obstructive lesions 429 +single ventricle physiology 405 spontaneous closure of defects 412 surgery 409 +treatment 409 Chandipura virus 239 Charcoal,activated 699 +Chediak-Higashi syndrome 358 Chest circumference 12 +Chest compressions 130, 710 Chickenpox, see Varicella Chikungunya 229 +clinical features 229 diagnosis 229 treatment 229 +Child abuse 769,770 manifestations 770 +Child mortality 2,3 Choanal atresia 366 Choledochal cyst 288 Cholelithiasis 287 Cholesteatoma 360 Cholesterol 90 Chromosomal disorders 636 Chronic bullous disease 686 Chronic diarrhea 299,303 +approach 299,300 causes 299 +Chronic glomerulonephritis 483 Chronic granulomatous disease 358 Chronic hepatitis B 322 +clinical features 322 management 322 prevention 323 +Chronic hepatitis C clinical features 323 epidemiology 323 treatment 323 +---------------------------------------'-"-d-_ex _ + + +Chronic inflammatory demyelinating polyradiculopathy 591 +Chronic kidney disease 493 anemia 495 +cause 493 +clinical features 494 hypertension 495 investigations 494 management 494,496 mineral bone disease 495 +Chronic liver disease 316 causes 316, 326 +cUnical features 316 investigation 317 +Chronic lung disease 171 +Chronic myeloid leukemia (CML) 607 adult variety 607 +juvenile 608 +Chronic suppurative otitis media 60 Cleft Ii p 177 +Cleft palate 177, 366 Cobalain (vitamin B12) 119 Cold chain 205 +Cold stress 144 Collodion baby 677 Coma 561 +grades 561 investigations 562 treatment 563 +Combination vaccine 203 Common cold 374 +Common variable immunodeficiency 186 Complementary feeding 91 +Conduct disorders 62 +Congenital abnormalities of kidneys and urinary tract 505 +Congenital adrenal hyperplasia 526 21-hydroxylase deficiency 526, 527 other variants 528 +Congenital diaphragmatic hernia 138, 178 Congenital heart disease 400 +classification 403 diagnostic approach 405 etiology 400 +genetic conditions 401 Congestive cardiac failure 396 +causes 397 +diastoUc dysfunction 396 prognosis 400 +time of onset of 397 treatment of 398 +Congenital nephrotic syndrome 482 Congenital rubella syndrome 272 Congenital syphilis 272 +Congenital toxoplasmosis 272 Conjunctivitis 162,668 Constipation 283 +ca uses 284, 285 management 284 +Constitutional growth delay 37 Convulsions, see Seizures Copper 122 +Cough 371 acute 371 +chronic or recurrent 371 diagnostic approach 394 +Cow milk protein allergy 301 + + +Cransynostosis 41 +Creatinine clearance 469 Crescentic glomerulonephritis 476 Cretinism, endemic 519 +Crigler-Najjar syndrome 312 Crimean hemorrhagic fever 239 Crohn disease 304 +Croup 368,376 congenital causes 369 +differential diagnosis 376 management 376 spasmodic 376 +Cryptococcosis 260 Cryptorchidism 540 Cushing syndrome 523 +evaluation 524 laboratory findings 524 management 525 +Cyanotic spells 411 Cyclic vomiting 280 Cystic fibrosis 393 +clinical manifestations 393 diagnosis 393 management 393 +Cystic kidney diseases 507 +Cysticercosis 277, see Neurocysticercosis Cystinosis 500 +Cystinuria 503 Cytomegalovirus infection 272 + +Daily nutrient requirements 89 Dentition 11 +Degenerative brain disorders 583 Dehydration +clinical assessment 73 +in severe malnutrition 102, 104 severe 73 +some 73 therapy 72 +DemyeU.nating disorders 580 Dengue infections 224 +algorithm 227,228 +clinical manifestations 225 differential diagnosis 225 epidemiology 224 management 226, 227 monitoring 228 prevention 228 +prognosis 228 severe 226 +Dengue shock syndrome 226 Depressor anguli oris muscle, +absence of 138 Dermatophytoses (ringworm) 692 Development +assessment 53 domains of 44 factors affecting 42 fine motor 49,50 gross motor 45, 49 language 52,53 milestones 49-55 normal 42 +personal and social 52 quotient (DQ) 54 +red flags signs 55 + +scales 55,56 +vision and hearing 53 Developmental dysplasia of hips +(DOH) 139, 141 Development screening tests 55 +CAT/CLAMS 56 Denver 56 +Goodenough-Harris drawing 56 Phatak's Baroda 56 +Trivandrum development 56 Development surveillance 56 Dhatura (belladonna) poisoning 702 Diabetes insipidus 519 +nephrogenic 501 Diabetes mellitus 541 +classification 541 clinical features 542 complications of 545 diagnosis 542, 545 epidemiology 541 insulin therapy 543 maternal 181 nutrition therapy 544 sick day care in 544 treatment 542, 545 type 2 544 +Diabetic ketoacidosis 546 clinical features 547 laboratory evaluation 547 management 547 +Diaper dermatitis 682 Diaphragmatic hernia 178 Diarrhea +acute,see acute Diarrhea chronic 299 +persistent 297 Diet +balanced 91 normal 90 +Dietary standards 90 DiGeorge syndrome 185 Digoxin,dose of 399 +Dilated cardiomyopathy 447 Diphtheria +clinical features 242 diagnosis 242 management 242 prevention 242 vaccines 193 +Disorders of sexual differentiation 537 classification 538 +evaluation 539 management 539 +Disruptive behavior disorders 62 Disseminated intravascular coagulation 353 +causes 354 +clinical and laboratory evaluation 354 diagnosis 355 +treatment 354 Diuretics 399, 748 Down syndrome 637 +associated abnormalities 638 clinical features and diagnosis 638 counseling 639 +cytogenetics 638 management 638 prenatal diagnosis 639 +1- _____ia __P__d_i_ri________________________________ +- +ss +e +E n +t +_ +1 +at +_ c +s +e + + +Drooling 370 Drowning 707 Drug eruptions 686 +Dry powder inhaler 388 +Duchenne muscular dystrophy 595 management 597 +Dysentery 296 Dyslexia 60 Dysphagia 282 Dysplasia, renal 505 Dyspnea 373 +differential diagnosis 282 management 283 +Dystrophinopathies 595 + +Early stimulation 56 Ebstein anomaly 423 Echinococcosis 277 Ecthyma 688 +Ectodermal dysplasia 678 Ectopic kidney 507 Eczematous dermatitis 680 +atopic 680 diaper 682 seborrheic 682 +Edward syndrome 639 Eisenmenger syndrome 428 Electroencephalogram (EEG) 550 Electrolyte +composition of body compartments 71 compositions of body fluids 73 imbalance in severe malnutrition 104 +Electromyography 551 Empyema thoracis 395 Encephalitis 568 +amebic 271 +clinical features 568 diagnosis 569 management 569 prognosis 569 +vaccine, Japanese B 201 Enteric fever 243 +carrier 244 +clinical features 244 complications 244 diagnosis 247 prevention 245 relapse 244 treatment 245 vaccine, typhoid 197 +Enuresis 468, 504 Eosinophilia 357 Epidermolysis bullosa 676 Epiglottitis 368, 376 Epilepsy 557 +classification 557 clinical features 557 duration of therapy 561 epidemiology 557 +errors in diagnosing 559 management 559 medications used 560 prognosis 561 +Epistaxis 365, 373 Eruption of teeth 11 Erythema infectiosum 216 Erythroderma 687 + +Ewing sarcoma 619 +Exchange transfusion 174, 176 +Exercise induced bronchoconstriction 389 Expanded program of immunization 205 Expressed breast milk 155 +Extracellular fluid 70 Extremely low birthweight 125 Eye +disorders 665 infections 667 +nutritional disorders 665 trauma 671 + +Facioscapulohumeral dystrophy 597 Failure to thrive 38 +causes 39 +clinical features 39 diagnosis 39 management 39 +Fanconi syndrome 499 Fats 89 +Fatty acid oxidation defects, mitochondrial 657 +Fatty liver disease 325 causes of 325 clinical features 658 diagnosis 658 treatment 658 +Febrile convulsions 556 prophylaxis 556 treatment 556 +Febrile neutropenia 622 Feeding +choosing method in newborns 159 complementary 91 +counseling for 91 gavage 160 +maturation of skills 159 paladai 160 +progression of oral 160 replacement 183, 237 +Fetal circulation 402 +circulatory adjustments at birth 402 Fever +definition 209 etiopathogenesis 209 evaluation of 209 management 209 short duration 210 with rash 212 +without focus 210, 211 Fever of unknown origin 211 Filariasis 276 +Fixed drug emption 687 Fluid +compartments 70 +daily requirement in neonates 146, 147 therapy 714 +Food fussiness 58 Foreign body +airway obstruction 711 aspiration 369, 391 removal of aspirated 727 +Freckles 686 Friedreich ataxia 580 +Fungal infections, see individual infections 359 + + +Galactosernia 655 Gastroesophageal reflux 280 Gastrointestinal bleeding 306 +causes of upper 306 causes of lower 307 +Gaucher disease 661 +GBS, see Guillain-Barre syndrome Genetic counseling 646 +Genetic disorders 635 therapy for 644 +Genodermatoses 675 +GER, see Gastroesophageal reflux Gestational age, assessment of 138 Giardiasis 270 +clinical features 270 diagnosis 271 treatment 271 +Gilbert syndrome 312 Gitelman syndrome 502 Glaucoma 670 +Glomerular filtration 466, 469 Glomerulonephritis +acute see Acute glomerulonephritis chronic 483 +crescentic 483 poststreptococcal 484 +Glucose-6-phosphate dehydrogenase deficiency 339 +drugs that cause oxidant stress in 339 Glycogen storage diseases 325, 656 +enzymatic deficiencies in 657 GM] gangliosidoses 662 +GM2 gangliosidoses 583, 662 Goiter 518 +causes of 519 endemic 519 +Granulomatosis with polyangiitis 634 Growth hormone deficiency 511 Growth hormone excess 513 +Growth assessment 11 brain 10 charts 13 +consequences of impaired 9 disorders of 35 +factors affecting 7 monitoring 14, 35 skeletal 11 velocity 10, 14 +Guillain-Barre syndrome 590 +Habit disorders 59 +Hand-foot-mouth disease 219 Hand regard 49 +Hantavirus 239 +Head circumference 12, 19, 27 Head tilt chin lift 711 +Health programs 3 Hearing loss 362 +causes 362, 363 +neon ata! screening 363 screening in older children 363 trea tmen t 363 +Heel prick (capillary blood) 730 Height 12, 13 +for age, boys 16, 21, 29 for age, girls 16, 20, 29 +Sf9 Essential Pediatrics + + +IMNCI, see Integrated management of neonatal and childhood illness +Impetigo 688 +Inactivated polio vaccine 192 Inborn errors of metabolism 647 +acute presentation 647 adjunctive therapy 650 biochemical autopsy 648 +chronic and progressive presentation 650 classification 647,648 +differential diagnosis 649 evaluation 648, 649,650,651 management 648,651 +Increased intracranial tension 570 Infant of diabetic mother 181,182 Infant mortality rate 2 +Infantile spasms 559 +Infantile tremor syndrome 580 clinical features 581 differential diagnosis 581 treatment 581 +Infectious mononucleosis 215,367 clinical features 215 +diagnosis 216 +Infective endocarditis 411, 443 antibiotic prophylaxis 446 clinical features 444 complications 445 +diagnosis 445 treatment 445,446 +Inflammatory bowel disease 304 clinica I features 304 +treatment 305 Inflammatory granuloma 572 Influenza +clinical features 238 prevention 201, 239 vaccine 201 +Injuries 704 prevention 706 +Inotropic agents 718, 747 Insulin therapy 543 +Integrated Child Development Services Program 109 +Integrated management of neonatal and childhood illness 751-766 +International normalized ratio 309 Interstitial nephritis 483 +Intestinal failure 308 +Intestinal lymphangiectasia 303 lntracranial space occupying lesions 570 Intraosseous infusion 731 +Intrauterine growth curves 137 Intrauterine growth retardation 2,155 lntussusception 287 +Iodine deficiency 122 classification of severity 520 disorders 123, 519 prevention 520 +Iron deficiency anemia evaluations 334 investigation 332,334 treatment 334 +Iron intoxication 702 + +Japanese B encephalitis vaccine 201 Jaundice 172, 311 +approach to neonate 173 + +breast milk 173 causes in children 312 +causes in neonates 173, 174 management 173 prolonged 174 +Juvenile delinquency 62 +Juvenile dermatomyositis 598,629 Juvenile idiopathic arthritis 625,628 +complications 628 investigations 626 subtypes 626 treatment 626 +Kala-azar (visceral leishmaniasis) 266 clinical features 267 +diagnosis 267 +HIV co-infection 288 prevention 268 treatment 267 +Karyotype 636 +Kangaroo mother care 148 jacket 149 +procedure 149 Kawasaki disease 631 Klinefelter syndrome 640 Kwashiorkor 99 +Langerhans cell histiocytosis 620 Laryngeal granuloma 369 Laryngitis 376 +Laryngomalacia 369 Laryngotracheal cleft 370 Laryngotracheobronchitis, +see Croup 368,376 Learning disabilities 60 +Legg-Calve-Perthes disease 625 Leishmaniasis +post kala-azar dermal 267 visceral, see Kala-azar +Length 11,13 for age 20,21 +Lentigines 686 +Lennox-Gastaut syndrome 559 Leprosy 690 +Leptospirosis 246 Leukemia 599 +see also Acute lymphoblastic leukemia, Acute myeloid leukemia +Leukocyte adhesion defect 358 Leukocytosis 357 +Leukopenia 357 Lichen planus 685 +Limb girdle muscular dystrophies 597 Liver abscess 310 +Liver biopsy 310,737 Liver failure 313 +acute 313,314 causes of acute 314 +chronic, see Chronic liver disease clinical features 314 investigations 315 +management 314 Liver,tumors 318,620 Liver transplantation 329 Loeffler syndrome 380 Low birthweight 124 +care of 155 extremely 125 + + +feeding of 158 +growth monitoring 161 Lowe syndrome 500 +Lower respiratory tract infections 3, Lumbar puncture 549, 732 +Lung abscess 391 Lupus nephritis 476 Lupus vulgaris 689 Lymphocytosis 357,358 +Lymphoid interstitial pneumonitis 23.: Lymphoma 608 +Hodgkin 608 +non-Hodgkin 611 Lymphopenia 358 +Lysosomal storage disorders 659 +Macrocephaly 39 Macroglossia 366 Macronutrients 88 Magnesium 82,121 +physiology 82 +Maintenance fluid requirements 71, 72 Malaria 260 +cerebral 261,266 clinical patterns 261 control 265 diagnosis 262 +differential diagnosis 263 epidemiology 260, 261 severe 262 +treatment of complications 266 treatment of severe malaria 263,264 treatment of uncomplicated +malaria 263 +Malnutrition, see Undernutrition 96 age independent indices 97 assessment 100 +classification 108 clinical features 98 +criteria for discharge 107 mild 98, 100 +moderate to severe 98, 102 pathological features 98,99 prevention of 108 +severe acute 97,100,102 Malrotation 288 +Mannan binding lectin deficiency 187 Mantoux test 254 +false positive and false negative 254 Maple syrup urine disease 652 Marasmus 99 +Maternal serum screening 646 Maternal to child transmission of HIV, +prevention of 235 Measles 213 +clinical features 213 complications 213 diagnosis 213 prevention 213 vaccine, measles 195 +vaccine,measles mumps rubella 195 Measles mumps rubella vaccine 195 Mechanical ventilation 719 +adjustment of setting 720 assisted 719 +indications 719,720 modes 719 +weaning from 720 +-------------------------------------'"-d_e_x __ + + +Meconium aspiration syndrome 170 Meconium stained liquor 128 Mediastinal syndrome 622 Megaloblastic anemia 335 +clinical manifestations 336 differential diagnosis 336 drugs causing 335 etiology 335, 336 laboratory evaluation 336 +Membranoproliferative (mesangiocapillary) glomerulonephritis 477 +Meningococcal vaccine 202 Meningitis, acute bacterial 563 +clinical features 563 complications 564 diagnosis 564 +differential diagnosis 565 epidemiology 563 prevention by vaccine 202 treatment 565 +Meningitis, tubercular, see Tubercular meningitis +Mental retardation 584 clinical features 585 etiology 584, 585 grades 584 +predisposing factors 585 prevention 585 +Mesangial proliferative glomerulo­ nephritis 477 +Metabolic acidosis 85 causes of 85 clinical features 85 treatment 85 +Metabolic alkalosis 86 causes 86 +clinical features 86 treatment 86 +Metabolic liver disease 324 Metachromatic leukodystrophy 584, 662 Metered dose inhaler 388 +MicrocephaJy 40 Micrognathia 366 Micronutrients 110, 749 +deficiency in severe malnutrition 105 Micropenis 540 +Micturating cystourethrogram 470 Mid-arm circumference 12, 97 Mid parental height 35 +Miliaria 683 +Millennium development goals 2 Minerals 121 +Mitochondrial disorders 658 diagnosis 659 +treatment 659 Mitochondrial inheritance 644 Mitra! regurgitation 438 +clinical features 439 differential diagnosis 439 hemodynamics 438 treatment +Mitra] stenosis, rheumatic 440 assessment of severity 441 clinical features 441 + + +differential diagnosis 441 hemodynamics 440 treatment 441 +Mixed connective tissue disease 630 Molluscum contagiosum 691 Mongolian spot 679 +Monocytosis 357 Moro reflex 143 Mortality rate 2 +early neonatal 3 infant 3 neonatal 3 under five 3 +Mucopolysaccharidoses 584, 659 clinical features of 661 +Mucormycosis 260 +Multicenter growth reference study 14, 56 MuJticystic dysplastic kidney 505 +Mumps 217 +clinical features 217 diagnosis 217 epidemiology 217 prevention 217 vaccine 195 +Murmur diastolic 406 +grade III or more, systolic 406 less than grade lll, systolic 406 +Munchausen by proxy 61 Myasthenia gravis 593 +congenital 594 treatment 594, 740 +Muscle dystrophies 595 congenital 597 facioscapulohumeral 597 limb girdle 597 +Muscle weakness 588, 589 +Mycobacteria other than tuberculosis 258 Myocarditis 447 +Myopathies congenjtal 594 inflammatory 598 metabolic 598 +Myotonic dystrophy 596 Myxedema 181 + +Nadas' criteria 406 Nail biting 59 +Nasal obstruction 365 causes 365 diagnosis 365 treatment 365 +Nasogastric tube insertion 728 Nasolacrimal duct, blocked 162 National immunization days 192 National Program 3, 769 +of Immunization 206 of Mid day meals 109 +of Nutritional Anemia Prophylaxis 109 Revised National Tuberculosis +Control 257 +Vector borne disease control 265 National Rural Health Mission 2-4 Nebulizer 389 +Necrotizing enterocolitis 165 Neonatal +death, causes of 124 + +examination 135, 136, 138 +fluid and electrolyte management 146 mortality rate 125 +reflexes 152 resuscitation 125 sepsis 163 +Neonatal cholestasis 327 clinical features 327 diagnosis 327 +etiology 327 management 328 +specific management in 328, 329 Neonatal sepsis 163 +Neonate +followup of high-risk 178 infections 162 +post-term 124 preterm 124 term 124 transport of 178 +Nephrogenic diabetes insipidus 501 Nephrocalcinosis, see Nephrolithjasis Nephrolithiasis 502 +cystinuria 503 +endemic vesical calculi 503 evaluation 502 +idiopathic hypercalciuria 502 management 504 +primary hyperoxaluria 503 Nephronophthisis medullary cystic disease +complex 509 Nephrotic syndrome 477 +clirucal features 47 congenital 482 steroid resistant 481 steroid sensitive 477 +Nerve conduction study 591 Net protein utilization 89 Neural tube defects 575 +clinical features 575 etiology 575 management 576 prevention 645 prognosis 576 +Neuroblastoma 616 clinical features 616 diagnosis 617 genetics 616 +occult 580 staging 616 treatment 617 +Neurocutaneous syndromes 586 Neurocysticercosis 572 Neurofibromatosis 586 Neuroirnaging 551 +Neuromuscular blocking drugs 721 Neuromuscular disorders 587 +approach to evaluation 587 Neuropathy, hereditary 590 Neutropenia 357 Neutrophilia 357 +Nevi 679 epidermal 679 melanocyte 679 +Newborn anthropometry 137 +___ _ss_ n_t iaiPed_ iatric_ ________________________________ +s +E +e +_ +_ +_ +_ +_ +_ +_ +_ +_ +_ + +care beyond few hours of birth 134 care in the initial few hours 133 screening 645 +Niacin (vitamin 83) 118 deficiency 118 +Non-Hodgkin lymphoma 611 clinical presentation 611 diagnosis 611 +epidemiology 611 management 612 +St. Jude staging system 612 +Non-ketotic hyperosmolar state 547 Nosocomial infections in PICU 721 +strategies to prevent 723 Nutrient daily requirement 89 Nutrition 88 +in critically ill children 720 failure 317 +Nutritional recovery syndrome 108 Nutritive value of common food +items 92 +Obesity 528 complications 529 constitutional 529 evaluation 529 management 530 +Obstructive lesions, cardiac 429 obstructive sleep apnea 367 Obstructive uropathy 506 Oliguria 468 +Omphalitis 162 +Oncologic emergencies 622 presentation and treatment of 622 +Oppositional defiant disorder 62 Optic neuritis 668 +Oral polio vaccine 191 +Oral rehydration solution 294 Oral thrush 162 +Organic acidurias 655 Organophosphorus poisoning 701 ORS, see Oral rehydration solution Ortolani's sign 141 +Osmolality 71, 467 Osteogenic sarcoma 619 Otitis externa 362 +Otitis media 359 acute 359 +chronic suppurative 360 complications 361 +Otomycosis 362 Otoscopy 360 Oxytocin reflex 151 +Palmoplantar kerotoderma 675 Pancreatitis +acute 289 chronic 289 +Pancytopenia 347 Pantothenic acid 120 Paracentesis, abdominal 734 Paracetamol poisoning 700 Paraplegia 578 +causes 578 flaccid 578 management 579 +pseudoparalysis 578 spastic 578 + +Parotitis, viral 370 +Patent ductus arteriosus 417 assessment of severity 419 clinical features 417 complications 419 treatment 419 +Pediatric advanced life support 710, 712 Pediatric basic life support 710 Pediculosis 694 +Pellagra 118 +Pelviureteric junction obstruction 506 Pemphigus vulgaris 655 +Penicillins 741 Peptic ulcer 288 +Pericardia! diseases 450 Pericarditis +Perinatal mortality ratio 125 Peripheral neuropathies 589 +Persistent pulmonary hypertension of the newborn 170, 456 +Peritoneal dialysis 734 chronic 497 +Peritonsillar abscess 367 Peroxisomal disorders 663 Persistent diarrhea 297 +clinical features 297 diets 298 etiopathogenesis 297 management 297 monitoring 299 +Pertussis 243 complications 243 diagnosis 242 epidemiology 242 management 243 vaccines 193, 194 +Pervasive developmental disorders 61 Pharyngeal injury 367 +Pharyngitis 366 +Pharyngotonsillitis, acute bacterial 367 Phenylketonuria 652 Pheochromocytoma 525 +Phototherapy 174, 175 Pica 58 +Pediatric intensive care 708 assessment and monitoring 708 indications for admission 708 +Pityriasis alba 695 Pityriasis rosea 685 Pityriasis versicolor 694 Pivoting 48 +Platelet function, qualitative disorders 349 Pneumococcal infections 241 +diagnosis 241 treatment 241 vaccine 199 +Pneumonia 577 +aliphatic hydrocarbons 380 atypical,primary 379 +Chlamydia pneumoniae 385 clinical features 377 +gram-negative organisms 380 etiology 377 +neonatal 171 pneumococcal 377 staphylococcal 378 streptococcal 379 + +viral 380 +WHO clinical classification 380, 381 Pneumothorax 171 +Poisoning 696, also see Individual poisons/ toxins +approach to suspected poisoning 697 clinical clues 697 +diagnosis 696, 697 indications of dialysis 700 laboratory evaluation 697 management 697 +Polycystic kidney disease 507, 509 autosomal dominant 507 autosomal recessive 507 glomerulocystic kidney disease 508 +Poliomyelitis +clinical features 218 diagnosis 219 +differential diagnosis 219 eradication 219 prevention 191,192,219 +vaccine, inactivated (IPV) 192 vaccine,oral (OPV) 191 +Polyarteritis nodosa 632 Polygenic inheritance 644 Polyuria 468 +causes 514 +differential diagnosis of 514 evaluation 515 +management 515 Pompe disease 657, 658 Portal hypertension 319 +causes 319 complications 320 investigations 319 management 320 +Positive pressure ventilation (see also Mechanical ventilation) 129, 720 +Poststreptococcal glomerulonephritis 474 clinical features 474 +laboratory features 474 management 474 outcome 474 pathology 474 +Potassium 76 +Prenatal diagnosis 645 invasive testing 646 +Protein energy malnutrition (PEM), see Malnutrition +Protein 88 quality 88 +requirements 89 Proteinuria 473 +conditions that present with 473 quantification of 473 +Pseudotumor cerebri 108, 575 Psoriasis 684 +Puberty 63, 531 +delayed puberty in boys 535 delayed puberty in girls 534 precocious puberty in boys 533 precocious puberty in girls 531 +Pulmonary arterial hypertension 410, 456 +clinical manifestations 456 management 457 +persistent pulmonary hypertension of the newborn 456 +prognosis 457 +----------------------------------------'"-d_e_x _ + + +Pulmonary function tests 373 Pulrnonic stenosis 433 +clinical features 433 treatment 433 +with intact ventricular septum 433 Pulse polio immunization 192 Pyoderma 687 +Pyridoxine 118 + +QRS, normal 459 Quadriplegia, see Paraplegia + +Rabies +immunization 203, 209 +post-exposure prophylaxis 203 vaccines 202 +Rapidly progressive glomerulonephritis, see Crescentic glomerulonephritis +Rash 212 macular 212 nodular 212 petechial 212 urticaria! 212 vesicular 212 +RDA, see Recommended dietary allowances Ready to use therapeutic food 107 Recommended dietary allowances 89, 90 Red blood cell indices, normal 332 +Red cell glycolysis, abnormalities in 339 Reflux nephropathy 486 +Refractive errors 469 Refractory rickets 114 Refsum disease 580 Renal biopsy 738 +Renal replacement therapy 497 Renal transplantation 497 Renal tubular acidosis 498 +distal (type 1) 498 Fanconi syndrome 499 hyperkalemic (type 4) 497 inherited forms 498 investigations 499 proximal (type 2) 499 +Respiratory acidosis 87 causes 87 +Respiratory alkalosis 87 causes 87 +Respiratory distress +non-pulmonary causes 169 pulmonary causes 168 syndrome 169 +Restrictive cardiomyopathy 448 Resuscitation of newborn 125 +algorithm 127 Apgar scores 126 +evaluation 126, 129, 131 initial steps 128 medications 132 +Reticulocyte count 332 Retinoblastoma 614, 668 +clinical features 615 diagnosis 615 genetics 616 treatment 615 +Retinopathy of prematurity 666 Retropharyngeal abscess 368 Reye syndrome 569 + + +Rheumatic fever 433, 443, 435 aortic regurgitation 441 aortic stenosis 429 +arthritis 435 carditis 434 +clinical features 434 erythema marginatum 436 etiopathogenesis 434 mitral regurgitation 438 mitral stenosis 440 prevention 438 +revised Jones criteria 435, 437 secondary prophylaxis 438 Sydenham chorea 436 treatment 437 +tricuspid regurgitation 442 Rhinitis 363 +allergic 363 viral 364 +Rhizomelic chondrodysplasia 663 Riboflavin 117 +Rickets 113 evaluation 113 +familial hypophosphatemic 114 nutritional 113 +refractory 114 +vitamin D deficiency 113 vitamin D dependent rickets 115 +Rickettsial infections 248 clinical features 248 prevention 250 treatment 249 +Rights of children 768 +role of the pediatrician 769 Ringworm 692 +Rooting 152 +Roseola infantum 216 Rotahaler 388 Rotavirus vaccine 198 Roundworm 274 +RTA, see Renal tubular acidosis Rubella +congenital 272 +vaccine, mumps measles 195 +Sarcoma, soft tissue 618 Scabies 694 +Scalp vein catheterization 729 Scleroderma 630 +Scorpion sting 703 Scrofuloderma 689 Scurvy 120 +Seborrheic dermatitis 682 Second heard sound 406, 407 +Sedation, analgesia and paralysis 721 common indication medications 722, 149 commonly drugs used for 722 +Seizures 552 +absence attacks 558 anticonvulsants 554 cause 553 +grand ma! 557 myoclonic 559 neonatal 558 partial 558 +Sepsis, neonatal see Neonatal sepsis Septic shock, management 718 +Severe combined immunodeficiency 185 + +Severe acute malnutrition 97 assessment 100 +management (see Malnutrition) 101 Sexual differentiation, disorders of 537 Sexual maturity rating 36, 64 +Sexually transmitted infections 65, 66 Shakir type 97 +Shock 715 septic 718 +monitoring 716 treatment 716, 717 +Short stature 35, 511, 513 causes 35 constitutional 37 +differential diagnosis 36 evaluation 35, 37, 512 familial 36 +management 513 +Sialoadenitis, bacterial parotid 370 Sickle cell anemia 344 +crises 345 infections 344 management 345 +laboratory studies 345 preventive care 345 Single kidney 505 +Single ventricle 405 Sinusitis 364, 672 Skin fold thickness 97 Snake bite 703 +Social smile 52 Sodium +deficit 74 physiology 73 +regulation of balance 72 Sore throat 366 +recurrent 375 Sphingolipidoses 661 +Spinal cord compression 622 Spinal muscular atrophy 588 Splenomegaly 310 +Spontaneous bacterial peritonitis 319 Standard deviation score 96 Staphylococcal infections 240 Staphylococcal scalded skin syndrome 688 Status epileptics 555 +evaluation 553 management 554 +Stem cell transplantation, see Hematopoietic stem cell transplantation +Steroid resistant nephrotic syndrome 481 agents for management 482 +Steroid sensitive nephrotic syndrome 477 clinical features 477 +complications 480 frequent relapses 479 laboratory findings 477 parent education 479 steroid dependence 479 therapy 480 +Stevens-Johnson syndrome 687 Still-birth 124 +Stomatitis 366 Strabismus 669 Stridor 368, 372 +acute 372 chronic 373 +_ E_s_s_e_nt-ia_1e_P__d_1_a_tic_r ___________________________ _ +s +_ +_ + + +Stunting 95 +Sturge-Weber syndrome 586 Stuttering 61 +Subacute sclerosing panencephalitis 584 Subdural effusion 573 +Subglottic stenosis 369 +Superior vena cava syndrome 622 Swallowing reflex 153 +Sweat chloride test 374 Sydenham chorea 579 +Syndrome of inappropriate antidiuretic hormone secretion 73 +Syphilis congenjtal 273 maternal 182 +Systemic lupus erythematosus 628 ACR criteria for 628 +diagnosis 628 +renal involvement 476 serology 629 treatment 629 + +T achyarrhythmias, see Arrhythmia Takayasu arteritis 631 +Tapeworm 276 +Target height 35, 37, 38 Tay-Sachs disease 583 Teeth, eruption of 11 Temper tantrums 58 Temperature, body +measurement of 144 disorders of 145 +Teratogenic drugs 182 Tetanus +clinical features 247 immunoglobulin 195 neonatal 247 pathogenesis 247 prevention 194, 248 treatment 248 vaccine 194 +Tetralogy of Fallot 420 clinical features 421 complications 422 diagnosis 422 treatment 422 +TGA, see Transposition of great arteries Thalassemias 341 +complications 342 intermedia 341 laboratory studies 341 major 341 management 342, 344 minor 341 +variants 341 Thiamine 117 Thoracocentesis 113 Threadworm 274 Thrombocytopenia +cause of 349 idiopathic 351 +neonatal alloimmune 352 Thrombosis 349 Thrombotic disorders 355 +evaluation 356 management 356 recurrent thrombosis 356 + + +Thumb sucking 59 Thyroid +assessment of function 516 disorders 516 +Tinea +capitis 692 corporis 693 +Tonsillopharyngitis, acute 374 +Total anomalous pulmonary venous connection 426 +Toxidromes 697 +Toxins, see also Poisoning 699 decrease absorption 698 enhancing elimination 699 laboratory identification 698 +Toxoplasmosis, congenital 272 Trace elements 121 +Tracheitis, bacterial 368 Tracheoesophageal fistula 176 Transfusions 723 +blood 723 complications 725 cryoprecipitate 725 plasma 724 platelets 724 +Transient hypogammaglobulinemia of infancy 186 +Transient tachypnea of newborn 171 Transposition of great arteries/vessels 424 +clinical features 425 corrected 426 +Transtubular potassium gradient 77, 501 Tricuspid atresia 422 +course 423 treatment 423 +Tricuspid regurgitation 442 management 443 +Triglycerides 89 +Trisomy 13 (Patau syndrome) 639 Trisomy 18 (Edward syndrome) 639 Tropical pulmonary eosinophilia 276 +TTKG, see TranstubuJar potassium gradient Tubercular meningitis 566 +clinical manifestations 566 diagnosis 567 +differential diagnosis 567 treatment 568 +Tuberculin skin test 254 Tuberculosis 250 +abdominal 305 clinical features 251 cutaneous 689 +diagnostic algorithm 250 drug resistant 258 management of contact 257 maternal 182 +pathology 251 treatment 256 vaccine 190 +Tuberous sclerosis 586 Tubular diseases 497 +investigations 464, 465, 470 presenting features 497 renal tubular acidosis 498 +Tumor lysis syndrome 622 Tumors, brainstem 571 Turner syndrome 536, 640 + + +clinical features 640 management 641 +Tympanostomy 360 +Typhoid vaccine, see Enteric fever 197 Tyrosinemia, hepatorenal 652 + +Ulcerative colitis 304 +Umbilical vessel catheterization 730 Undescended tests 540 Undernutrition, see Malnutrition 95 +classification 96, 97 epidemiology 95 indicators of 95 +Underweight 95 +Universal rnunization Program 205 Upper respiratory infections 374 +Urea cycle defects 653 clinical features 654 diagnosis 654 management 654 +Urinalysis 468 Urinary anion gap 85 +Urinary tract infections 483 clinical features 483 diagnosis 484 +evaluation 485 imaging studies 484 microbiology 483 +predisposing factors 483 prevention of recurrent 485 treatment 484 +Urolithiasis, see Nephrolithiasis Urticaria, papular 695 + +Vaccine associated paralytic polio­ myelitis 192 +Vaccine, also see Individual infec-tions 190, 203 +combination 203 effectiveness 189 failure 189 +killed 190 live 189 +protective efficacy 189 storage 205 +toxoid 190 +Variceal bleeding 306 Varicella (chickenpox) 214 +clinical features 214 complications 214 diagnosis 214 treatment 214 vaccine 197 +Varicella zoster immune globulin (VZIG) 197, 208 +Vascular access 713 intraosseous 713 intravenous 713 +Vascular ring 369 Vasculitides 631 +Venous catheterization 728, 729 Ventilation +bag and mask 129 corrective steps 130 positive pressure 129 +Ventral suspension 45 Ventricular septa! defect 414