A Manual of Essential Pediatrics, Second Edition, the revised and updated edition provides essential state-of-the-art information on childcare right from birth to adolescence. The book serves as a practical guide to pediatricians for the diagnosis and treatment of common disorders and diseases of neonates, children, and adolescents. The author has used his experience of over 50 years to cover core pediatric topics such as growth and development, behavior and developmental disorders, common day-to-day illnesses, immunizations, and nutrition in a simple and succinct manner.

1. Introduction to Pediatrics
1
“We are guilty of many errors and many faults. But our
worst crime is abandoning the children, neglecting the
foundation of life. Many of the things we need can wait, the
child cannot. Right now is the time his bones and flesh are
being formed, his blood is being made. And his senses are
being developed. To him we cannot answer tomorrow. His
name is TODAY.”
– Gabriela Mistral
1.1 Goal of Child Care
The basic aim and goal
of pediatricians is to
ensure that every child
is assisted to achieve his
or her optimal genetic
potential for physi-
cal growth and mental
development. The spec-
trum and manifesta-
tions of diseases in chil-
dren are affected and
modified by their age and developmental status, and con-
versely various diseases can adversely affect the growth
and development of children. There is an increasing evi-
dence to suggest that seeds of most adult diseases such as
obesity, metabolic syndrome X, type 2 diabetes mellitus,
stroke, and osteoporosis are sown during childhood. Pedi-
atrics deals with the promotion of health and well-being
of children and not merely diagnosis and treatment of dis-
eases of children. Pediatricians should, therefore, provide
health promoting, preventive, curative, and rehabilitative
services to children from birth through adolescence. Chil-
dren truly constitute the foundation of a nation because
healthy children grow to become healthy and strong
adults who can actively participate in the developmental
activities of a nation.
Differences between the Health Care
of Children and Adults
1. Children are dependent on their parents or caretak-
ers and health care professionals for their nutritional
and health needs. Educated, well-informed, econom-
ically independent, and adjusted parents can provide
better health care to their children.
Health care of children is the
most cost-effective strategy—
saving the life of a child pro-
vides at least 50 years of lease
of productive life! And child
survival is indeed the key for
the success of family welfare
and population control pro-
gram.
2. Children cannot explain or express their discomfort
and therefore identification and diagnosis of dis-
eases may be delayed if parents are not intelligent,
observant, and concerned. Pediatricians need greater
clinical acumen and skills to diagnose diseases in chil-
dren because they depend on the secondhand infor-
mation or history provided by parents or caretakers.
3. Childhood period is characterized by rapid physical
growth and mental development. Depending on the
developmental status, diseases behave differently at
different age groups. Diseases produce non-specific
symptoms and signs and take a more serious course
in newborns and infants.
4. Diseases in children may adversely affect their physi-
cal growth and mental development. Children with
recurrent or chronic diseases are prone to develop
nutritional problems and stunted growth.
5. Because of their wide range of body sizes (ranging in
body weight from 1 kg at birth to more than 50 kg at
adolescence) and developmental status at different
ages, the children need medical equipment of differ-
ent sizes and sophistication.
6. Nutritional and caloric needs of children per unit
body weight are higher because they need extra
energy for rapid physical growth and high level of
physical activity. Nutritional disorders are more
common in children compared with adults. Their
needs for fluids, electrolytes, calories, and nutrients
are calculated on the basis of their age and body
weight.
7. Children are at increased risk for developing a variety
of infectious diseases during their first or nascent con-
tact with microbes because they lack any protective
antibodies. Adults in general are less likely to suffer
from common infectious diseases because they have
developed protective antibodies by virtue of previous
infections or immunizations during childhood.
8. Children are not mini-adults because they have ana-
tomical and functional immaturity of various body
organs at different stages of life. They are prone to
rapidly develop life-threatening medical emergencies
because of their physiological instability. Children
are like flowers—they can rapidly wither following
an acute illness but are endowed with tremendous
recuperative capabilities; and when tended with
care, compassion, and due concern for their physio-
logical handicaps, they bloom back to life with equal
ease.
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2. A Manual of Essential Pediatrics2
Infants Children aged between birth and up to
their first birthday are called infants. They should be
provided exclusive breastfeeding (even water should
not be given) up to first 6 months of life and contin-
ued for at least 1 year and preferably longer.
Toddler or preschool child Children aged between
1 and 3 years are called toddlers or preschool chil-
dren. They are most vulnerable to nutritional disor-
ders and growth faltering because they are started
on complementary or weaning foods and are ex-
posed to a variety of infections with increased risk
of diarrheal disorders. Adequate nutrition or optimal
nutrition during 0 to 3 years of age is most crucial for
optimal physical growth and brain development. It is
believed that linear growth or height achieved at the
age of 3 years is a good predictor of ultimate adult
height or stature.
Under-5 children Children between the age of 0 and
5 years are called under-5 children. They are particu-
larly vulnerable to a variety of vaccine-preventable
diseases, diarrheal disorders, and respiratory infec-
tions.
School-going children Children aged between 3 and
5 years are often sent to play schools or kindergar-
tens and they join regular schools after 5 years of age.
When children are first admitted to crèches or play
schools, they often suffer from frequent gastrointesti-
nal or respiratory infections because of close contact
with a large number of children. After entry to a regu-
lar school, the risk of intercurrent infections among
healthy children becomes less.
Adolescents Adolescence is a phase of childhood,
which is characterized by rapid physical growth,
sexual maturation, and emotional development. The
physical changes and sexual maturation during ado-
lescence are triggered by hormonal changes. Girls
mature both sexually and emotionally earlier than
boys by 2 years. In girls, pubertal changes take place
between the age of 10 and 16 years. A large majority
of girls begin their sexual development at the age of
10 years and have their first menstrual period around
9. The drug dosages in children are calculated on the
basis of their age, body weight, or surface area. In view
of small doses in infants, the safety margin of drugs
is small and hence extra caution and care should be
taken while administering drugs to children.
10. Vital signs vary in children depending on their age.
Body temperature is maintained within the narrow
range of 98.2°F ± 0.7°F (36.8°C ± 0.4°C) at all ages.
However, temperature is more labile and unstable
in newborns and infants. Vital signs at different age
groups are shown in Table 1.1.
11. Congenital malformations and developmental disor-
ders including genetic and chromosomal disorders,
are mostly seen during childhood. Cancer and ma-
lignant disorders do occur in children, but they are
more common among adults. Atherosclerosis, coro-
nary artery disease, and adult-onset diabetes melli-
tus occur in adults, but the seeds of these diseases are
often sown in early life because of poor fetal growth
(intrauterine growth retardation) and overnutrition
or unhealthy lifestyle during childhood.
1.2 Age Groups in Children
Pediatricians look after children from birth up to 12 years
of age. Until now adolescents or children between 12 and
18 years of age were not looked after either by internists
(physicians for adults) or by pediatricians. In most devel-
oped countries in the west, adolescents are being looked
after by pediatricians and there are separate male and
female wards for adolescents. In India, many pediatricians
provide ambulatory or outpatient department (OPD) care
to adolescent children, but hospitals do not have separate
wards for adolescents.
Newborns Children aged between birth and up to
28 days of life are called newborns or neonates. They
are delicate and have distinctive health problems,
with high morbidity and mortality demanding spe-
cialized health care facilities.
Table 1.1 Vital signs at different ages
Vital signs Newborns (term baby) Infants (up to 1 y) 2–5 y Above 5 y
Temperature (oral °F) 98.2 ± 0.7 98.2 ± 0.7 98.2 ± 0.7 98.2 ± 0.7
Heart rate (beats/min) 140a
120 100 80
Respiratory rate (rate/min) 40a
30 20 18
Blood pressure (mm Hg) 60/40b
70/50 90/50 110/80
Abbreviation: y, year(s).
a
Heart rate and respiratory rate in a newborn are double that of an adult.
b
Blood pressure in a newborn is one-half that of an adult.
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3. 1 Introduction to Pediatrics 3
when compared with children belonging to other Asian
countries of the region (Table 1.2). Undernourished chil-
dren are prone to develop frequent day-to-day infections
and directly or indirectly account for more than 50% of all
deaths in childhood. Because of progressive elimination of
dietary deficiencies of calories and proteins, deficiencies
of micronutrients have assumed public health relevance.
Recent studies conducted at the National Institute of
Nutrition, Hyderabad, India, have shown that more than
50% of apparently healthy school-going children from
middle-income families have subclinical or biochemical
deficiencies of micronutrients.
The provision of optimal nutrition is of fundamen-
tal importance to improve child health and survival.
The nutrition-sensitive age groups that should be
accorded special attention include fetal period (70%
brain growth), preschool children or first 3 years of life
(determinant of ultimate adult height), and adolescence
or phase of sexual maturation (contribute 20% of ulti-
mate stature and 50% of adult bone mass). It is impor-
tant to remember that nutrition during early life (fetal
and infancy) is entirely transmaternal. It is, therefore,
necessary to ensure adequate nutrition throughout the
“life cycle” of girls along with provision of nutritional
supplements to the mother during pregnancy and lac-
tation to enhance fetal growth and improve the quality
of breast milk. Promotion of exclusive breastfeeding for
first 6 months, weaning with home-based nutritious
foods, prevention of day-to-day infections by ensur-
ing adequate environmental sanitation and personal
hygiene, and timely administration of various vaccines
are mandatory to improve nutrition of children and
enhance their survival.
12 years of age. An average boy starts puberty around
12 years and achieves sexual maturity during 14 to
18 years. When full sexual maturation is achieved, the
epiphyses of the long bones fuse with their diaphyses
and there is no further linear growth or increase in
height. After completion of puberty, a girl becomes a
woman and a boy becomes a man.
1.3 Maternal Health and Child Survival
Health and well-being of children is intimately linked with
health, nutrition, education, and awareness of their moth-
ers. Mothers are the creators and sustainers of human
progeny. Health and well-being of a baby in the womb
depends on the health and nutrition of his/her mother
(not the father!) because mother is the sole provider of
food and nutrition to the fetus for 9 months. Healthy moth-
ers produce healthy babies and are in a better position to
look after the health and well-being of their children. It is
important, therefore, to provide a life cycle approach for
the care of girl children with a focus on equal opportuni-
ties for their nutrition (from birth through infancy, child-
hood, adolescence, pregnancy, and lactation), health care,
education, dignity, empowerment, and status to have a say
in the society.
1.4 Interaction between Nature and Nurture
The growth and development (including intelligence,
emotional, social, courage, confidence, and enthusiasm
quotients) of children depend on the interaction between
their genetic potential that is racial and ethnic background,
constitution, and genome and environmental conditions,
and availability of adequate nutrition, safe drinking water
and lack of pollution, physical and fun activities, and love
and emotional support from parents, family members,
friends, and teachers. Among various environmental fac-
tors, adequate nutrition is most critical for optimal growth
and well-being of children.
1.5 Importance of Nutrition
Undernutrition is the core health problem in children.
Children are vulnerable to develop nutritional disor-
ders because they are dependent on their parents and
caretakers to meet their nutritional requirements. Their
caloric and protein requirements are higher to sustain
their rapid growth velocity and meet the nutritional
demands of physical activity and intercurrent infec-
tions to which they are highly vulnerable. In India, 28%
of babies are of low birth weight (<2.5 kg) and approxi-
mately 48% of under-5 children have stunted growth. The
nutritional status of under-5 children in India is dismal
Table 1.2 Salient nutritional indicators of under-5
children in Asian region
Country
Low birth weight
babies (%)
Underweight
children (%)
Stunted
children (%)
India 28 43 48
Bangladesh 22 41 43
Pakistan 32 31 42
Myanmar 9 23 35
Indonesia 9 18 37
Thailand 7 7 16
China 3 4 10
Source: The State of the World’s Children, UNICEF 2012.
Note: Low birth weight babies, birth weight of less than 2.5 kg
irrespective of the period of gestation; underweight children, weight
less than 22 SD of median weight-for-age of NCHS/WHO reference
standard; stunted children, height less than 22 SD of median height-
for-age of NCHS/WHO reference standard.
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4. A Manual of Essential Pediatrics4
During clinical as-
sessment, be relaxed and
focused and visualize
every patient as a puz-
zle and enjoy in trying
to solve it. Pediatricians
need all the skills of a
detective, lawyer, and
a judge to understand
and diagnose the disease process. They should be thorough
in taking a detailed history and doing a complete physical
examination. According to Henry Cohen, “most errors in
clinical evaluation are made by doing a cursory and hurried
examination and not due to lack of knowledge and skills.”
1.8 Management Strategies
There are several guidelines and principles to provide
rational therapy. Efforts should be made to practice evi-
dence-based pediatrics, which should be complemented
by personal experience, expertise, and common sense to
promote best child-care practices. Symptomatic and spe-
cific therapy should be instituted after making a tentative
diagnosis and a “shotgun” therapy is condemned. Every
patient with fever should not be treated with antibiotics
or antimalarials unless they are indicated.
Every child is unique
and no two children are
alike. There are differ-
ences in the constitution,
genetic stock, nutritional
status, immunologic
integrity, ecology, envi-
ronment, and so on. It is important to remember that not
only the same medicine from different doctors has different
effects but also the same medicine from the same doctor is
likely to have different effects on different patients. An
identical disease such as “cough and cold” can behave dif-
ferently in different patients. Rapid strides have been made
in the field of pharmacogenomics in an attempt to produce
tailor-made medicines to suit the genetic constitution of
patients.
There are a large
number of modalities
of therapy pertaining
to different systems
of medicine to treat
various diseases (see
Box). The availability of a large number of options indi-
cates that none is foolproof and one should try to exploit
various modalities to provide healing—keeping in mind
that nature, time, patience, faith, hope, and prayer are
great healers. Nevertheless, it is important to remember
that availability of safe and effective vaccines, antibiot-
ics, lifesaving drugs, management of emergencies, and
surgical interventions for repair and replacement of body
“The physician should have
faith in his clinical acumen and
should treat the patient and
not his laboratory reports.”
– John Apley
“When a lot of medicines are
suggested for a disease that
means it cannot be cured.”
– Anton Chekhov
It is a paradox that not only undernutrition but also
overnutrition is assuming public health relevance among
children belonging to the affluent segments of our society.
Surveys have shown that almost one-fourth of adolescents
in public schools are obese. These children are prone to
develop metabolic syndrome X, type 2 diabetes mellitus,
and cardiovascular diseases early in adult life. Therefore,
the key to child survival and ensuring good quality of life
is to provide optimal nutrition by preventing both under-
as well as overnutrition. It is important that fundamentals
of nutrition, mothercraft, and family life education should
be taught to teenage boys and girls attending high school
so that they grow to become well-informed citizens and
responsible parents.
1.6 Doctor–Patient Relationship
Because of various reasons there is a gradual erosion of
time-honored sacred relationship between the doctor
and patients. When parents have faith and trust in their
doctor, it augments the process of healing. Therefore,
the parents and patients must have faith and trust in
their physician and physicians must have confidence
in themselves and the drugs they prescribe. Physicians
should strive to handle sick children and their parents
with confidence, competence, due concern, and com-
passion to establish a bond of trust and faith. On the
other hand, hurry, worry, indecision, and lack of self-
confidence weaken the doctor–patient bond. Physicians
should try to listen more and talk less while taking
history and interacting with parents/patients to allow
them to give vent to their observations, feelings, and
concerns.
1.7 Art of Pediatrics
Children should be han-
dled as children (not
patients!) and with due
care and compassion as
well as in a relaxed and
playful manner. Physi-
cians should always
greet the child with a
smile and not scare the child by staring or looking intently
into his eyes. Unlike adults, children distrust a person who
looks directly into their eyes. “Sneaky” observation is the
best mantra to elicit the cooperation of a child. Offer a toy
and ignore the child while taking history—the best way to
make friends with a child is not to try. Examine children
with warm hands and warm heart preferably in the com-
fort of lap of their mothers. In case of school-going chil-
dren, it is best to get firsthand information directly from
the child.
“We should not allow the tech-
nology to further dehumanize
medicine and we must treat
children not only with our
heads but also with our hearts.”
– Meharban Singh
“There are no short cuts to
physical diagnosis. It is learnt
by all the five senses alert. Eyes,
ears, nose and palpating fingers
are the gems of a physician – in-
tact brain is the necklace.”
– Hippocrates
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5. 1 Introduction to Pediatrics 5
To avoid therapeutic misadventures, there are five mes-
sages or pearls of wisdom encapsulated in the above quote:
1. Many diseases are self-limiting and they recover
spontaneously without any drugs. Nature, time, and
patience are the three great physicians.
2. We should not be enamored and fascinated or carried
away to use newer drugs that have not withstood
the test of time and we should remember the well-
known dictum that “old is gold.”
3. Art of medicine should not be sacrificed at the altar of
technology.
4. Patients should not be viewed as systems or organs
but in their totality—body, mind, soul, and society. We
should provide holistic “care” and not mere “cure.”
5. Medicines should not cause more harm to the patient
than the disease itself for which they are prescribed.
We must use those medicines that have withstood
the test of time with an assured efficacy and safety
track record.
1.10 Ethical Concerns
There is increasing commercialization and gradual decline
of human values at all levels of our society and doctors are
no exception. The Box summarizes various correlates and
types of malpractices that are prevalent in our country.
Common correlates and types of unethical practices
Change of social values and everyone wants to become
“rich overnight.”
Doctors are competing with each other to create rev-
enue for the corporate hospital by fair or foul means.
Exorbitant cost of medical education in the private
sector.
Unnecessary diagnostic studies to get “cuts” or the
laboratory is owned by the physician.
“Kickbacks” for referrals.
Needless hospital admissions.
Superfluous medical procedures such as endoscopies
and biopsies.
Unnecessary surgical procedures or even surgical
operations.
Self-promotion through advertisements.
It is important that medicine should be practiced with
a conscience, dignity, and professionalism and without
any ulterior or sole motive of making money. Mother
Teresa extolled that “medicine should not be considered
merely another profession but a mission in life.” Physicians
should never criticize or say a slighting word against their
organs are the greatest assets of the modern system of
medicine.
Therapeutic modalities and interventions
to promote healing
Drugs such as allopathic, homeopathic, ayurvedic,
siddha, and unani
Surgery: corrective repair and replacement
Psychotherapy
Physiotherapy
Acupuncture and acupressure
Hypnotherapy
Magnetic therapy
Yoga
Music therapy
Aroma therapy
Gemology
Naturopathy
Visualization
Reiki
Meditation
Art of living
Prayer
1.9 Holistic Care
Patients should not be viewed as systems, organs, tissues,
cells, and DNA. They must be viewed in totality—body,
mind, heart, and soul, and that too not in isolation but in
context with the dynamics of ecology, family, friends, and
society. We should treat the child and not his or her disease or
investigation reports. Every contact with the family should be
harnessed to provide “holistic care” and not mere “cure.” We
must give advice regarding lifestyle changes, importance
of personal hygiene, benefits of breastfeeding, importance
of safe drinking water, environmental sanitation, optimal
nutrition, immunizations, and prevention of accidents.
The principles of rational management of diseases and
provision of holistic care have been beautifully summed
up by Sir Robert Hutchison in the following quotation:
“From inability to let well alone, from too much zeal for the
new and contempt for what is old, from putting knowledge
before wisdom, science before art and cleverness before
commonsense, treating patients as cases, from making the
cure of the disease more grievous than endurance of the
same, good Lord deliver us.”
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6. A Manual of Essential Pediatrics6
combination of continuous registration and half-yearly
surveys. There are wide variations in indices of health in
different states of the country and between affluent seg-
ments and underprivileged urban and rural communi-
ties. The current population of India is estimated to be
approximately 1,224,614,000 (more than 1.2 billion). The
country is overcrowded and thickly populated because it
accounts for 2.4% of the global land area where 17.5% of
the world’s population lives (Table 1.3). There has been
colleagues. It is important that doctors remain transpar-
ent in their dealings and avoid unnecessary investigations,
procedures, and hospital admissions. There is an urgent
need that medical students, both graduate and postgradu-
ates, be taught the subjects of humanities, social sciences,
communication skills, and medical ethics.
1.11 Art of Communication
Most parental complaints of mismanagement originate
because of lack of communication or because of abrasive
or callous attitude of the doctor or health care professional
rather than because of lack of skills or faulty technical
management of the patient. Humility, concern, empathy,
and compassion are crucial to generate faith and provide
emotional support to the family. Be relaxed, patient, and
polite during interaction with the patient’s family and
always consider patient as a client. Even if the enquiry or
query of the parents is illogical, repetitive, and irritating,
physicians must respond with due grace, equanimity, and
calmness without any hurry, anger, or arrogance.
The physician must
establish a rapport with
the child and his/her
parents to provide them
emotional support and
win their faith, trust,
and confidence. The
pediatrician who exhib-
its evidences of worry,
hurry, and indecision
is unlikely to inspire
any confidence in their
patients or attendants.
What physicians do not say and what they say, how and
when they say, make all the difference between helping and
not helping the patients. A skillful physician knows when to
sedate with drugs, when to console with words, and when
to treat aggressively for cure or palliatively to provide symp-
tomatic relief. The patients and attendants have emotional
feelings and one should avoid saying that “nothing can be
done” (because something can always be done), “there is
nothing wrong”—even when it is a functional disorder. For a
critically unwell child, always give a guarded prognosis that
can by tempered with hope and godly benevolence.
1.12 Salient Vital Statistics
Vital statistics refer to systematically collected demo-
graphic data pertaining to vital health parameters. In India,
the main sources of vital statistics include the census;
registration records of vital events such as births, deaths,
and sample registration system; and the National Family
Health Survey (NFHS). Sample registration system obtains
annual information on birth and death rates, fertility rates,
and age-specific mortality rates in the country through a
“A person may have learnt a
great deal and still be an ex-
ceedingly unskillful physician
who awakens little confidence
in his patients. . . . The manner
of dealing with patients, the
manner of winning their confi-
dence and the art of soothing
and consoling them. . . . All this
cannot be learnt from books.”
– John Apley
Table 1.3 Salient demographic, maternal, and child
health indicators
Indicators Values
Basic indicators
Annual births 27,165,000
Neonatal mortality rate 32
Infant mortality rate 48
Under-5 mortality rate 63
Life expectancy at birth
Male 66 y
Female 68 y
Adult literacy rate
Male 88%
Female 74%
Nutritional status
Low birth weight babies 28%
Under-5 children
Underweight 43%
Wasted 20%
Stunted 48%
Maternal indicators
Antenatal coverage
At least once 75%
At least four times 51%
Skilled attendant at delivery 53%
Urban 76%
Rural 47%
Institutional deliveries 47%
Maternal mortality rate
(per 100,000 live births)
250
Total fertility rate 2.6
Annual population growth rate 2.5
Abbreviation: y, year(s).
Source: The State of the World’s Children, UNICEF 2012.
Note: Underweight, below 22 SD from median weight-for-age;
wasted below 22 SD from median weight-for-height; stunted
below 22 SD from median height-for-age.
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7. 1 Introduction to Pediatrics 7
5. Ensure availability of good quality antenatal care
facilities and safe delivery (either at a health post or
by a trained birth attendant) in 100% of cases.
6. Ensure availability of essential newborn care facili-
ties and promote exclusive breastfeeding, universal
immunizations, and early detection and manage-
ment of common childhood illnesses such as diar-
rhea and respiratory infections by promoting oral
rehydration solution and rational use of antibiotics.
7. Health and social activities should be reinforced
and integrated by active involvement of non-
governmental organizations to improve the socio-
economic status and quality of life at the individual
family level.
8. The World Health Organization and the United
Nations Children’s Fund have launched integrated
management of neonatal and childhood illnesses
modules by providing hands-on clinical skills to
health workers to manage common health problems
in children with the help of algorithms. Apart from
rational management of common diseases, health
workers promote breastfeeding and provide immu-
nizations as well as health and nutrition education.
The emphasis has shifted from purely curative ser-
vices to a package of comprehensive health promo-
tive and preventive services at each contact of the
health worker with the families. Under the National
Rural Health Mission, it has been proposed to create a
new cadre of community-based female health func-
tionaries, named as accredited social health activists
(ASHAs), to provide essential health care services at
the doorstep of people.
1.14 Hospital Care of Sick Children
Children wards and hospitals for ill children should have
their distinct identity along with necessary facilities and
features to make them child-friendly. There should be
small cots with railings as well as standard adult beds for
older children. Each bed should be provided with a cen-
tralized source of oxygen and suction. Because of shortage
of nurses and to avoid separation anxiety and fear of stran-
gers and strange environment, the mother or a lady atten-
dant should be allowed to stay with the child round the
clock. A comfortable padded bench and a locker should be
provided next to the bed for the comfort of the mother or
attendant. Two bays adjacent to the nursing station should
be provided to admit moderately sick children requiring
intravenous fluid therapy and close monitoring by the
nurses. These patients should be visible to the nurses from
the nursing station through the glass walls.
The walls of the ward should be decorated with colorful
and innovative designs of indigenous cartoon characters.
A procedure room should be available in each unit. Each
pediatric unit should be provided with three to four inde-
pendent rooms with an attached bathroom for isolation
gradual improvement in the health statistics and health
indices in the country, but they are far from being satisfac-
tory. The National Population Policy 2000 has laid down
the health objectives and national sociodemographic goals
to be achieved (see Box).
National population policy goals to be achieved by India
Provide the essential unmet needs for basic reproductive
and child health infrastructure, services, and supplies.
Ensure free and compulsory school education up to
14 years of age.
Achieve 100% deliveries by trained health personnel.
Achieve 100% immunization coverage.
Achieve 100% registration of pregnancies, births, and
deaths.
Reduce infant mortality rate to below 30 per 1000 live
births.
Reduce maternal mortality rate to below 100 per
100,000 live births.
Promote small family norm.
Achieve universal access to safe drinking water, health
care, information, and counseling.
1.13 Strategies for Child Survival
The four pillars of good health are sound genetic consti-
tution, safe environment, wholesome food, and healthy
lifestyle. The National Population Policy and the National
Rural Health Mission have outlined several strategies to
improve child survival and reduce avoidable human wast-
age by implementing the following strategies:
1. Health and well-being of children is intimately linked
to the health, education, and nutrition of their moth-
ers. Healthy and well-informed mothers produce
healthy children and are in a better position to take
proper care of their children.
2. Girl children should be accorded essential health
care, nutrition, and formal education without any
discrimination. Ensure 100% literacy rate and provide
adequate nutrition throughout the life cycle of girls—
infancy, childhood, adolescence, pregnancy, and lac-
tation. Women are the creators and sustainers of the
progeny and they should be financially independent
and empowered to have a say in the society.
3. Ensure availability of safe drinking water and satis-
factory environmental sanitation and provide health
and nutrition education to the community on a pri-
ority basis.
4. Provide adequate infrastructure and operationalize
credible facilities for essential family welfare, repro-
ductive, and child health services within easy reach.
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8. A Manual of Essential Pediatrics8
by children while playing does not disturb other children
who are ill. A dining room is an essential requirement
because children do eat better in the company of other
children. Children are fussy in their food habits and their
fussiness becomes worse when they are unwell. Dining
room with a television set and other ancillary facilities
does encourage and motivate ill children to eat better. The
washrooms and toilet facilities should cater to the needs
of children as well as their mothers and attendants. Chil-
dren should be provided with a colorful and clean dress
from the hospital and their dress should be changed daily.
Bed linen and sheets must also be changed daily because
children are more likely to soil them. The colorful dress of
the nurses and avoidance of white coat by the doctors are
likely to enhance nurse–child and doctor–child relation-
ship and cooperation.
of children who are immunocompromised or suffering
from contagious diseases. They should be provided with
gowning and hand washing facilities. In each pediatric
unit, provision must also be made for a pantry and formula
room to dispense special diets. A well-equipped pediatric
intensive care unit (PICU) with all the essential monitoring
and therapeutic electronic equipment should be provided
to look after critically ill children with life-threatening
medical disorders. On an average 20% of beds should be
earmarked for pediatric emergencies—a 100-bedded chil-
dren ward should have a 20-bedded PICU.
Children should be provided home-friendly ambience
in the hospital. Efforts should be made to keep them busy
and in good mood. A playroom with necessary toys and
indoor games should be available. Playroom should be
located in the corner of the ward so that the noise made
Further Reading
Behrman RE. Overview of pediatrics. In: Kliegman RM, Behr-
man RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pedi-
atrics. 18th ed. New Delhi, India: Elsevier; 2007:1–12.
Maguire P, Pitceathly C. Key communication skills and how
to acquire them. BMJ 2002;325(7366):697–700.
Parsons TJ, Power C, Logan S, Summerbell CD. Childhood
predictors of adult obesity: a systematic review. Int J Obes
Relat Metab Disord 1999;23(Suppl 8):S1–S107.
Saunders J. The practice of clinical medicine as an art and as
a science. Med Humanit 2000;26(1):18–22.
Singh M. The Art and Science of Baby and Child Care. 3rd ed.
New Delhi, India: Sagar Publications; 2007.
Singh M. The art of pediatric diagnosis. In: Pediatric Clini-
cal Methods. 4th ed. New Delhi, India: Sagar Publications;
2011:1–11.
Singh M. Ethical considerations in pediatric intensive
care unit: Indian perspective. Indian Pediatr 1996;33(4):
271–278.
Singh M. The art, science and philosophy of child care. Indian
J Pediatr 2009;76(2):171–176.
United Nations Children’s Fund. The State of the World’s
Children. New York, NY: UNICEF; 2012.
Commonly Asked Questions
Why pediatrics is equated to veterinary medicine?
In a lighter vein, pediatrics is equated to veterinary medi-
cine because young children cannot explain the symptoms
of their disease. When in discomfort, they merely cry but
are unable to explain the site or the nature of discomfort
or pain. However, an intelligent and observant mother (at
times even the father!) can explain the nature of symptoms
and sequence of events. Nevertheless, pediatricians do need
greater clinical acumen and skills to diagnose the nature of
disease in children. Most school-going children can give an
accurate account of their illness and they must be directly
asked to explain the nature and sequence of their symptoms.
Why are children more prone to develop
nutritional problems?
Undernutrition is the core health problem in children.
Children are dependent on their parents and health
care professionals for their nutritional and health needs.
Unlike other mammals, human babies take much longer
to become independent. They need extra calories and
additional micronutrients to sustain their rapid physical
growth and high activity level. They are prone to suffer
from recurrent day-to-day infections including acute
diarrhea that further compromises their nutritional sta-
tus. Children have strong likes and dislikes and they are
fussy or finicky in their food habits. The average caloric
needs of infants are around 120 kcal/kg, which is at least
three times that of an adult (40 kcal/kg).
What diseases are more common in children
compared with adults?
Children are more likely to have diseases and disorders
because of structural and functional immaturity of various
body organs, infections, infestations, nutritional disorders,
congenital malformations, developmental disorders, and also
inborn errors of metabolism because of genetic disorders.
What do you understand by transmaternal
nutrition?
During fetal life and infancy, which is the most crucial and
rapid phase of child development, nutrition is provided
to the baby entirely through maternal sources. During
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9. 1 Introduction to Pediatrics 9
of Parents.” Such organizations bring together families of
children having similar medical problems and help form a
network and learn from each other by sharing mutual con-
cerns and difficulties and by effective utilization of avail-
able specialized services.
How to handle a family when its child dies in
the hospital?
Despite all the techno-
logical advances, medi-
cine can never achieve
immortality. It is as
natural to die as to be
born. During physicians’
career, they are likely
to face several “end-
of-life situations” and deaths despite of their best efforts.
The coping of death of a child in the hospital is a painful
and challenging experience for everybody concerned with
the care of the child. Death deflates our ego and teaches
us humility and provides strength to face and accept the
greatest reality and truth of life that we should handle with
equanimity, composure, and confidence. During the care of
critically sick children in intensive care unit, it is important
to show due concern, care, and compassion to the parents
and keep them duly informed about the condition and care
of their child. It is important that physicians not only pro-
vide state-of-the-art care to the child but also make the
parents and attendants perceive that what was humanely
possible was done for the care of their baby. The desire of
parents that death should occur in the familiar atmosphere
of home rather than a hospital should be honored. A fam-
ily’s wish for religious support (such as amulets, mantras,
and holy water) and the presence of a priest at bedside
should be allowed. The family should be emotionally and
spiritually prepared before declaration of death. The news
of death should be conveyed with utmost compassion but
in no unmistakable terms that the child has died despite
of best intents and efforts. When a child is conscious and
dying, the parents should be at his bedside holding his hand
and talking with him to allay his fears and assist him to
express his concerns, desires, and emotions.
“Death is certain for the born,
and rebirth is inevitable for the
dead. You should not, there-
fore, grieve over the inevita-
ble.”
– The Bhagvad Gita
pregnancy, nutrition and well-being of the mother deter-
mine the adequacy of fetal growth, health, and well-being
of the fetus. After birth, exclusive breastfeeding is recom-
mended for the first 6 months of life. The adequacy and qual-
ity of breast milk is determined by the health and nutritional
status of the mother. Therefore, during fetal life and the first
6 months of infancy, nutritional status and well-being of
the baby is entirely dependent on the nutritional status and
nutritional supplements taken by the mother during preg-
nancy and lactation. To provide a strong foundation and
good start to life, it is crucial to provide a life cycle approach
to health care and nutrition of girl children from infancy
through adolescence, pregnancy, and lactation. Women
indeed are the creators and sustainers of human progeny.
How to communicate bad news to a family?
When a child is suffering from a chronic or incurable dis-
ease or an affliction with lifelong disability, the parents
are likely to respond with disbelief, anger, shock, or feeling
of hopelessness. The news should preferably be given to
both the parents simultaneously in a relaxed sitting with
due concern, compassion, and empathy. The facts should
be explained in a simple language without any medical
jargons. The nature of disease, likely prognosis, available
therapeutic interventions, the cost of care, etc., should be
explained. Physicians should allow the parents to ventilate
their feelings and concerns and try to answer their queries
in an honest and unambiguous manner. They should try
to follow the well-known philosophy, “talk less and listen
more,” that is why God has given us one mouth and two
ears. Physicians should be pragmatic but not pessimistic
and remain hopeful, which is a great healing force, and
also remember that miracles do happen. We should be
careful and diplomatic in conveying the nature of disease
without hurting parental feelings. Instead of bluntly say-
ing that “your child is mentally retarded,” it is preferable
to use words wisely, for example, the child is rather “slow”
or having “developmental delay.” In Indian society, giving
spiritual advice to parents of such children is common.
For example, an advice such as, “God has chosen you to
provide care and comfort to this special child because you
are so compassionate, caring and sensitive human being”
may encourage the family to join “Self Help Associations
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