- Section 1: Introduction to Pediatrics
- Section Editor: Piyush Gupta
Section Editor Piyush Gupta
1.1 Evolution of Pediatrics
KN Agarwal
Pediatrics is the medical science for children, who are in a phase of active growth and progressive development. The word pediatrics and its cognates mean healer of children; derived from two Greek words: pais (child) and iatros (doctor or healer).
Newborns, toddlers, children, and adolescents have physical and emotional needs and health concerns different from adults. They are growing at varying rates in different phases of life—somatic growth, growth and development of brain, lymphoid tissue enlargement, and sexual development; thus energy needs and body metabolism remain active. In contrast adults are in a static maintenance phase, thus their macro- and micronutrient needs are more or less regulated and unchanging. Pediatricians take care of all these needs from birth up to age of 18 years. Present estimates are that brain growth completes around 25 years of age. The science of pediatrics has intimate relationship with mother from conception and birth, making obstetrics, gynecology, and pediatrics almost inseparable. In addition, it is hard to recognize diseases in young children with inherent difficulty in oral communication, and in whom eliciting clinical information is problematic.
DISEASES OF CHILDREN AND THEIR MANAGEMENT IN ANCIENT TIMES
India
The “Atharva Veda” (1,000 bc), a medical textbook explaining how to treat diseases, described breastmilk as nectar. “Charaka Samhita” (400–200 bc) and “Kashyap Samhita” (written by a pediatrician around sixth century bc to second century ad) described importance of breastmilk and advised breastfeeding from the first day of birth. “Sushruta Samhita” (dealing with surgical procedures; 600 bc) stated breastmilk as beverage of immortality. Unfortunately, it advised discarding of colostrum for the first 3 days and advocated feeding of honey and butter to facilitate discharge of meconium. Infant bath with lukewarm water and feeding of cereal and/or lentil (annaprashan) was recommended after 6 months of age.
Charaka knew that blood vessels brought food to various parts of the body and carried wastes away. He also made the earliest Indian reference to smallpox. Madhava (700 ad) practiced inoculation to keep people from catching smallpox, by scraping pus or scabs from the patient and administering as an inoculation, either by sticking it into the skin on a needle, or by blowing the powder up the nose.
Egypt
Ebers Papyrus (1550 bc) is a summary of the medical and surgical therapeutics practiced in ancient Egypt. In a tiny pediatric section which is mainly prognostic it reads as follows:
- To get a supply of milk in a woman's breast for suckling a child, warm the bones of swordfish in oil and rub her back with it.
- Prognosis for a child on the day of its birth: If it cries nicely, it will live; if it cries badly, it will die. If it wails loudly, it will die; if it drops its face downward, it will die immediately.
Ebers Papyrus also describes a few other topics including breastfeeding, a cure for worms, and treatment of eye diseases.
Islamic Empire (Iraq, Iran, Israel, Lebanon, and Syria)
Islamic physicians studied in depth all the medical observations and logic of Hippocrates, his followers, and Galen, combined with the work of the Indian physicians Sushruta and Charaka, whose books were translated into Arabic around 750 ad. Their observations helped to develop useful cures for some diseases. Another achievement of these practitioners was that they started the world's first hospitals, where the contagious patients of smallpox and measles were isolated and treated.
Al Razi (870–900 ad), Persian physician, wrote in a book the first description of how to differentiate measles and smallpox. However, he did not mention inoculation though it was already being done in India. Ibn Sina, the great Arabian physician (known as Avicenna in Europe, 990 ad) discussed tetanus, worm infestations, convulsions, meningitis, and umbilical abscess. He was the first to observe that tuberculosis (TB) and smallpox are contagious.
China
Pediatrics was one of the oldest specialties within Chinese medicine and dates from the early first millennium. This form of Asian medicine is the oldest and second largest medical system in the world today and is used by one quarter of the world's population. Children according to Chinese belief are weak and susceptible to diseases that affect the lungs (such as colds, coughs, allergies, and asthma) and the spleen (or digestive complaints such as colic, vomiting, diarrhea, indigestion, and stomach aches). In traditional Chinese medicine, there are four primary methods of treating children—dietary therapy, Chinese herbal medicine, Chinese pediatric massage, and acupuncture.
Greece
Around 300 bc and afterward Greek physicians established a logical system for understanding disease. “Hippocratic Writings”, named after the first and most famous of these physicians, (460 bc) give descriptions for cephalhematoma, hydrocephalus, clubfoot, worm infestations, diarrhea, scrofula, asthma, and mumps. Significant advances were made in childbearing with the introduction of the “Hippocratic Corpus” in the third century bc, though this document advised the practice of many superstitions.
Galen (200 ad) suggested advancement in medicine for women, though he focused mostly on specific diseases with some aspects of labor. He also wrote of ear discharge, pneumonia, intestinal prolapse, and possibly rickets.4
Soranus of Ephesus (98–138 ad) wrote in the second century on childbirth and obstetrics. For birth, the mother was made to sit on a birthing stool with a midwife in front of her and female aids standing at her sides. In a normal head-first delivery, the cervical opening was stretched slightly, and the rest of the body was pulled out. He instructed the midwife to wrap her hands in pieces of cloth or thin paper so that the slippery newborn did not slide out of her grasp. On the care of the newborn, his teachings as described in “On Diseases of Women” were followed to a large extent. He was the first to advise the salting and saddling of the newborn infant, a practice dating back to 600 bc. He also described a testing of the breastmilk by the behavior of a drop of milk placed on fingernail. This continued for over 1600 years.
Weakness at birth was attributed to prematurity, with heavy mortality. But Isaac Newton (1643–1727), Christopher Wren (1632–1723), and Jonathan Swift (1667–1745) were all premature infants, yet all lived a long vigorous life.
HISTORY OF MODERN PEDIATRICS
Major events related to child health are listed in a chronological order in Table 1.
Europe (United Kingdom, Belgium, Denmark, Italy, France, Germany, and Sweden)
In 15th century, four pediatric books were published in succession describing general pediatric ailments such as cough, ear infection, measles, smallpox, rheumatism, and diarrhea. These were written by Paulus Bagellardus (Italy, 1472, De Infantium Aegritudinibus et Remediis), Bartholomaeus Metlinger (Germany, 1473, Ein Regiment der Jungerkinder), Cornelius Roelans (Belgium, 1483, no title), and Heinrich von Louffenburg (Germany, 1491, Versehung des Leibs).
This was followed by detailed description of diseases in children. Eucharius Roesslin (Germany, early 16th century) wrote a book on Midwifery and Pediatrics, which reviewed 35 common ailments including many infections. Faventinus de Victorious (Italy, 1544) published a book with chapter on aphthous ulcers, measles, and smallpox. Thomas Phaer (England, 1544) published the first English language pediatric book, “The Boke of Chyldren” with chapters on meningitis, diseases of the ear, quinsy, diarrheal disorders, worm infestations, smallpox, measles, fever, and a disease description similar to Kawasaki disease.
Many infectious disorders were described subsequently. Giovanne P Ingrassia (Italy, 1553) differentiated scarlet fever from measles. Hieronymus Mercurialis (Italy, 1583) wrote about King's evil (scrofulous glands). Guillaume de Baillou (France, 1640) was the first to describe whooping cough as distinct entity covering the 1578 epidemic, as well as rubeola and scarlet fever. Johannes Sgambatus (Italy, 1620) made important descriptions of diphtheria while Thomas Bartholin (Denmark, 1646) described its contagious nature and mode of death by throttling.
The second English language book by Robert Pemell (1653) covered extensively many common infestations, otitis, oral ulcers, fevers, smallpox, measles, and erysipelas. The third English book in 1664 by J Starsmare covered the same topics including scrofula. Thomas Sydenham (England) described chorea in 1686, measles in 1670, and scarlet fever in 1675. Willis (England, famous for circle of Willis) described pertussis in 1675. Walter Harris (England, 1689) wrote a book on diseases of infants covering plague, venereal diseases, and strongly advocated inoculation against smallpox. This popular book had 18 editions and continued for another 53 years. John Fothergill (England, 1748) described ulcerative pharyngitis, diphtheria, and scarlet fever.
Chickenpox was described in 1760 by François Boissier de Sauvages (France). In 1765, Nils Rosén von Rosenstein (Sweden) described scarlet fever of 1744 epidemic in detail including the poststreptococcal nephritis. The credit of describing tubercular meningitis in three clinical stages with autopsy findings goes to Robert Whytt (Scotland, 1768).
Michael Underwood's (UK) book on diseases of children in 1784 was probably the best early published treatise on pediatric diseases. It had 17 editions and provided first descriptions of poliomyelitis and sclerema. Neonatal tetanus was first described by Joseph Clarke (Ireland) 1789. In the same year Edward Jenner published his report of 23 years of vaccination to prevent variola (smallpox).
By late 1700s and early 1800s, the need to attend specifically to the care, development, and diseases of children became more apparent and specialization in pediatrics evolved, particularly in Germany and France. The Society for Infant Therapeutics was formed in Germany in 1883. The British Pediatric Association was established in 1928 with George Frederic Still as the first President. The Royal College of Paediatrics and Child Health status was granted to British Paediatric Association in 1996. Its official journal “Archives of Diseases in Childhood” started its publication in 1926.
The first generally accepted pediatric hospital in Europe, the Hôpital des Enfants Malades (Hospital for Sick Children), opened in Paris in June 1802. The famous Great Ormond Street Children's Hospital of London was established by Charles West in 1848 followed by Hospital for Children at Edinburgh in 1856.
Pediatrics in the USA
The Father of American Pediatrics is considered to be Abraham Jacobi (1830–1919), a German pediatrician, who arrived in New York in 1853 and established the pediatrics chair at the New York Medical College in 1861. He is credited with the organization of the first pediatric society, publication of pediatric journal, and development of pediatric departments in New York hospitals. He was a prolific writer and taught extensively about the feeding and hygiene of children. He, in association with pioneers such as Luther Emmett Holt in New York, J Forsyth Meigs in Philadelphia, and William McKim Marriott in St. Louis rapidly expanded the specialty through their writings and teachings. The first independent pediatrics hospital was founded in Philadelphia in 1855 followed by Boston (Massachusetts) in 1869. The American Academy of Pediatrics was established in 1930 and the American Board of Pediatrics in 1933.
Luther E Holt Sr., who succeeded Jacobi, wrote the book, “The Care and Feeding of Children” in 1894, which was later developed into the “Holt's Pediatrics.” JP Crozier published “The Diseases of Infants and Children”, which in turn became Griffith and Mitchell's “Pediatrics”, then Mitchell and Nelson's “Pediatrics”; Waldo E Nelson's “Pediatrics” in 1954, and in 1984 “Nelson's Pediatrics”, edited by Richard Behrman. It has been the world's most trusted pediatrics resource for over 80 years. Pediatrics specialties have developed in diagnosis and management with approach of intrauterine diagnosis and treatment, identifying genetic disorders and study of genomics. The advances continue to provide the medical community with new diagnostic tools and therapies. Today in addition to general pediatrics, pediatricians can choose to specialize in a number of fields, including:
- Adolescent medicine
- Child abuse
- Developmental and behavioral pediatrics
- Neonatology
- Pediatric allergy and immunology (In the USA, allergy is the biggest culprit, as it impacts 14.4 million kids, or 20% of children 17 and under)
- Pediatric cardiology
- Pediatric critical care
- Pediatric dermatology
- Pediatric emergency medicine
- Pediatric endocrinology
- Pediatric gastroenterology-hepatology
- Pediatric hematology
- Pediatric nephrology
- Pediatric neurology
- Pediatric oncology
- Pediatric ophthalmology
- Pediatric pulmonology
- Pediatric psychiatry
- Pediatric rheumatology
Impact of genetics in pediatric illnesses ranges from as low as 5% of pediatric illness (in a General Hospital), to 70% of children admitted to an acute neonatal intensive care unit in the USA. The present day training is incorporating identification and management in primary health care.
Obesity tops the list of health concerns. The Centers for Disease Control and Prevention (CDC) reports that more than a third of US children are overweight or obese. Healthy food is advised in schools with more physical exercise.
Other pediatric specialists especially those in pediatric surgery, pediatric urology, or pediatric radiodiagnosis, are not necessarily pediatricians; however they undergo training in their own fields, and then receive additional specialty pediatric training.
HISTORY OF PEDIATRICS IN INDIA
Pediatrics made a formal beginning in Mumbai (erstwhile Bombay) in 1928, under the leadership of George Coelho, called the Father of Pediatrics in India. He was the head of the department of pediatrics at the Bai Jerbai Wadia Hospital for Children, the first independent children's hospital in India. In 1929, Dr Coelho started the Association of Pediatrics of India in Bombay in 1950. Pediatric departments soon came into existence at other centers, Nair Hospital, Mumbai (Shantilal Sheth), Patna (LSN Prasad), Delhi (PN Taneja), and Indore (JN Pohowalla).
In 1933, Dr KC Chaudhry founded the first independent pediatric journal namely, the “Indian Journal of Pediatrics”, in Kolkata (Calcutta). In 1948, he started the Indian Pediatric Society. By 1958, the Indian Pediatric Society organized nine national pediatric conferences in different cities and in 1961 the first Asian Pediatric Conference was held at New Delhi. His efforts to make pediatrics an independent subject are worth mentioning.
The state of Tamil Nadu has the honor and pride of having created the first chair of professor of pediatrics in India at the Madras Medical College (Chennai) in 1948 with the appointment of Professor ST Achar.
The Indian Pediatric Society and the Association of Pediatricians of India combined to form the Indian Academy of Pediatrics (IAP) as the single representative body of pediatricians of India and the first national conference of the IAP was held in Pune in 1964. The official journal of the IAP “Indian Pediatrics”, incorporated the “Indian Journal of Child Health” and the “Journal of the Indian Pediatric Society” and commenced publication in January 1964 from Kolkata.
The academy has promoted different specialties in the field of pediatrics through its various chapters. One of the major activities undertaken by the IAP since its inception is to organize continuing medical education programs all over the country. IAP has its office in Mumbai while Delhi is the seat of its official publication, “Indian Pediatrics.”
Pediatric Education in India
Dr AM Sur, Nagpur (University of Bombay) was the first to start pediatrics examination in MBBS. Medical Council of India decided in 1997 that pediatrics will be a separate subject for examination of undergraduate (MBBS) training. The first postgraduate course for diploma in child health was started at Bai Jerbai Wadia Hospital for Children in 1944 under University of Bombay (Mumbai) in 1946. First MD pediatrics course was also started at Nagpur.
Doctorate of Medicine (DM) courses were started late with gastroenterology in Postgraduate Institute of Medical Education and Research (PGIMER) at Chandigarh in 1989, followed Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow in 2009. DM in neonatology also began at PGIMER, Chandigarh in 1989. Subsequently DM neonatology courses have begun in other centers including All India Institute of Medical Sciences (AIIMS), New Delhi. In 1991, SGPGIMS, Lucknow, started DM in clinical genetics and reserved one seat each for pediatric postgraduates for DM courses in neurology, cardiology, gastroenterology, and immunology. AIIMS, New Delhi now offers DM courses in pediatric neurology (2009), nephrology (2013), and pulmonology (2013). PGIMER, Chandigarh offers DM courses in pediatric critical care, pediatric hemato-oncology, child and adolescent psychiatry, and pediatric rheumatology (2013). The first MCh course in pediatric surgery was started at AIIMS, New Delhi in 1972.
PAST, PRESENT, AND FUTURE
Throughout human history, numerous advances have improved the quality and longevity of life around the globe. Dating back to ancient civilizations, there is evidence of societies working to improve the health of the general public. The Babylonian sewage systems were among the first designed to protect the water supply from contamination and disease. Similarly, Indus valley civilization of South Asia (Mohen-jo-daro) was prominent in hydraulic engineering, had flush toilets, connected to common sewerage. The discovery of pasteurization by Louis Pasteur in the 1860s helped to ensure the safety of food supplies throughout the world. With the implementation of the constitution of the World Health Organization (WHO) in 1948, the mass TB immunization campaign with bacillus Calmette-Guérin vaccine in 1950, and the onset of the Malaria Eradication Program in 1955, many of the important developments related to global health in modern times occurred in the post-World War II period of the 1940s and 1950s. In 1980, smallpox was officially eradicated from the planet. The WHO (March 2014) has declared its South East Asia region polio-free (80%), as the disease is still endemic in Afghanistan, Nigeria, and Pakistan. The dreaded “Measles” remains a continued risk for importation of disease and occurrence of outbreaks in communities. Recent outbreaks of diseases erroneously thought by many to be contained by country borders or eliminated by vaccines have highlighted the need for proper training of all pediatricians in global health. Beyond infectious diseases, they should know how to care for other conditions in global child health, ranging from malnutrition to the nuances of care for immigrant and refugee children, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). The recent coronavirus disease-2019, pandemic has taken a heavy toll world over. This virus is mutating and becoming more serious. Fortunately world was successful in developing vaccine against Corona very fast.
In the 2020 Global Hunger Index, India ranks 94th out of the 107 countries demonstrating the seriousness. The report also said that anemia prevalence among adolescent girls is twice that of adolescent boys. Malnutrition caused 69% of deaths of children below the age of 5 years in India, according to the State of the World's Children 2019, UNICEF said that every second child in that age group is affected by some form of malnutrition. This includes stunting (35%), wasting (17%), and overweight. With the prevalence of overweight and obesity in children being 15%, childhood obesity is now an upcoming epidemic in India. With 14.4 million obese children, India has the second-highest number of obese children in the world, next to China. Only 42% of children (in the age group of 6–23 months) are fed at adequate frequency and 21% get adequately diverse diet. Timely complementary feeding is initiated for only 53% of infants aged 6–8 months.
The potable water, hygienic food, and essential immunizations can only help India, to meet proclaimed objectives of the UN General 7Assembly as the Decade of Action on Nutrition 2016-25. This present state of undernutrition can create future generation with poor mental functions including cognition, soft neurological signs, and low physical stamina.
1.2 Child Health: Concepts and Concerns
Piyush Gupta, Neha Thakur
Fundamental to understanding of the field of pediatrics is the understanding of the term “health” and “disease”. Let us first look at how most of the people understand “health” and “disease”.
THE CONCEPT OF HEALTH
Health is a fundamental human right, recognized in the Universal Declaration of Human Rights (1948). It is also an essential component of development, vital to a nation's economic growth and internal stability. It is a well-known fact now that better health outcomes play a crucial role in reducing poverty.
Naturalist versus Normativist Theory
Most people consider health to be an absence of any perceptible disease. Thus, for many, health is understood as an absence of any disturbance in the somatic functions of the body and is an objective phenomenon. This is popularly known as the naturalist's theory. For this school of thought, there are only these two absolute categories which a doctor should understand and follow, e.g., a kidney is diseased or not. The other school of thought discards the “objective” nature of the definition of health and considers health with reference to the degree to which the person fulfills one's social roles. This is known as the normativist's theory. Medical science is embedded in the social constructs and thus health cannot be restricted to somatic disturbances alone.
Definition of Health
“Health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity” [World Health Organization (WHO)], 1948. This is a conceptual and a utopian definition of health. It is an ideal goal that is elusive. Can the physical, mental, and social wellbeing be ever “complete”? Nonetheless, it acts as the benchmark for the whole humanity to strive for. At a pragmatic level, this definition fails because by this definition everyone is labeled as unhealthy. As it was not possible to attain this level of health, “absence of somatic disturbances” were still considered as healthy even after the launch of this definition.
In 1984, the WHO gave an operational revised definition of health defining it as “the extent to which an individual or group is able to realize aspirations and satisfy needs, as to change or cope with the environment is a resource for everyday objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities.”
Health is not an absolute phenomenon, but a gradient ranging from worst health status to the best health status, and therefore it is challenging to define the exact cut off point for discriminating between the healthy and nonhealthy.
Defining Health in Children
The standard WHO definition cannot be applied to children as such because of a very basic difference between an adult and a child, i.e., the child is growing and developing. Thus, in a child mere absence of a disease is insufficient to define health; not growing or developing appropriate to age also needs to be viewed as not being normal and hence not in good health. Health for children and adolescents (0–19 years) should thus be defined as the state of physical, mental, social, and spiritual wellbeing that allows the child to grow and develop optimally to attain his/her full genetic potential as an adult.
THE CONCEPT OF DISEASE
Definitions
Illness: Illness is the subjective sense of feeling unwell. In small children this must be sensed by the caregivers.
Disease: The pathological process which is what is diagnosed by the pediatrician. Caregivers may approach the pediatrician for an illness. However, it is important to know that a child may be ill but not diseased.
Sickness: Sickness is the social construct associated with disease. A sick role is what the caregiver assumes based on his/her perception of the disease. This perception is acquired from the society in which the caregiver lives.
Illnesses or health-related conditions which may not be categorized as a disease at one point of time may later be labeled as a disease, as we understand more about the condition. For example, obesity even though not considered as a disease till a few years back is now being considered as a disease by some proponents of this view and treated by using various medical and surgical methods.8
There are instances when parents report an illness but pediatrician may not diagnose it as a disease and the parents may feel upset as they may start doubting themselves or the doctor. But this is due to limited understanding about many signs and symptoms. As more diagnostic methods and tools evolve it may be possible to label the illness as a disease. Labeling a child as diseased or nondiseased is thus conditional to the extent of understanding of the associated clinical presentation at that point of time.
Causation of Disease: The Epidemiological Triad
Disease occurs because of an interplay between an agent, a susceptible host, and an appropriate environment. These three together constitute the epidemiological triad, as shown in Figure 1. The center of the triad represents time, i.e., length of disease process, incubation period, etc. A disease can be eliminated or prevented by controlling any or all these factors or the interplay between these three factors.
Agent
An agent is one, which can cause a disease. The size of the inoculum or dose of the agent must be enough to cause the disease. It must be virulent enough to attack the host and can be either living or nonliving. Living agents include various bacteria, viruses, fungi, protozoa, etc., and are usually responsible for infectious diseases. Nonliving agents directly responsible for inflicting a disease exist in the form of physical (electric current, extremes of temperatures, pressure, or sound), chemical (poisons, endogenous wastes as urea, bilirubin, ammonia), mechanical (motor vehicle, mechanical force), nutritive (deficiency or excess intake of various food elements), and social (illiteracy, poverty) factors.
A disease may have single or multiple agents. In the case of a living agent, its ability to produce a disease mainly depends on four attributes: (1) infectivity, (2) pathogenicity, (3) virulence, and (4) susceptibility.
- Infectivity: It is defined as the ability of a living agent to enter and multiply in a host. It depends upon the dose of the inoculum. The more the number of infective particles, the more is the degree of infectivity. It is also thought of as the minimum number of particles or agents required to establish infection in at least 50% of the hosts [infectious dose (ID50)]. This number may vary with the agent, route of its administration, its source, and with a few host factors like age or race. Measles is an infection with high infectivity. Leprosy has low infectivity.
- Pathogenicity: It is defined as the ability of the agent to produce disease in the host. The pathogenicity is also altered by many host and environmental factors, apart from dose, route, and source of infective inoculum.
- Virulence: It is defined as the ability to produce severe clinical manifestations including complications, death, and sequelae. One of the simple methods for assessing virulence is by estimating the case fatality rate (CFR). Virulence also depends on the same factors as those in infectivity and pathogenicity.
- Susceptibility: It is defined as the ability of the agent to survive in the host or in a free state. Susceptibility, therefore, depends on both intrinsic (host) as well as extrinsic (environmental) factors.
Immunogenicity: It is defined as the ability of the agent to produce a specific immunity. An agent may induce humoral, cellular, or mixed type of immune response in a host. Immunogenicity is altered by various host factors (age, nutritional status) as well as agent factors (dose and virulence of the inoculum). The intrinsic ability of agents in inducing and effecting a long-lasting immune response differs in different organisms. For some organisms, a single exposure results in a lifelong immunity (measles), while bacteria causing cholera or pneumonia are devoid of producing an everlasting immune response.
Host
A host is one in whom the disease manifests, for example, the human being. Various attributes of children may render them susceptible to a disease. These attributes include certain biological and social traits. Genetic characteristics such as human leukocyte antigen (HLA) haplotype, race, age, and sex may be important in the causation and outcome of a disease. Social factors such as socioeconomic status, school exposure, peer group, caretakers, behaviors, etc., are other important host characteristics.
The clinical outcome of the entry of a pathogen in the body depends on two interacting forces: (1) virulence of the micro-organism, and (2) the resistance mechanisms of the body. Resistance of the body is determined by immunity.
Immune system is an organization of cells and molecules with a defined function to protect against infective, autoimmune, and malignant disorders. A successful pathogen needs to breach several surface barriers such as keratinized layers of skin, mucosal layers with associated enzymes, mucus, etc. Microbes that overcome these initial barriers are exposed to the next level of defense, viz., the innate (nonspecific) immunity and acquired (specific) immunity; both of which have two components each—cellular and humoral.
Environment
All things surrounding the human body are considered part of the environment. In the context of community medicine, environment implies the external environment. Environment for man is not limited to the climatic conditions alone. The various environmental factors are classified into physical, biological, and social environment.
- Physical environment: The physical aspects of the environment include air, water, light, heat, radiation, gravity, pressure, and various chemical agents. Man exerts a great deal of control over these factors. Of late, the population explosion and industrialization are resulting in a heavy degree of air, water, noise, and other kinds of pollution.
- Biological environment: Certain diseases do not occur in some areas because the agent, or vector cannot exist in that environment due to biological reasons. The biological environment includes (A) infectious agents of disease, (B) reservoirs of infection, (C) vectors that transmit disease, and (D) plants and animals.
- Social environment: The social factors relevant to health include the socioeconomic status, social customs, and traditional beliefs. Old beliefs may provide resistance to new health practices. Social factors like isolation or alienation also produce diseases like schizophrenia, depression, and suicide.
DISEASES OF PUBLIC HEALTH IMPORTANCE
The basis for labeling a disease as a public health problem is that it affects a large proportion of population exerting a great burden on the community. It may be noted that there is no single prevalence cut off for all health problems to be labeled as a public health problem. There are different prevalence cut offs for different health problems such as iodine deficiency, vitamin A deficiency, etc.9
In addition, diseases which have the potential to spread rapidly such as Ebola in recent times would also qualify as a public health problem in spite of not being widely prevalent.
Equity and Inequality in Health
Equity and equality have different connotations for health and should not be used interchangeably.
Equity
It is concerned with (A) creating equal opportunities for health and (B) bringing health differentials between communities, down to the lowest possible level. It implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential if it can be avoided.
Health Inequality
This can be defined as differences in health status or in the distribution of health determinants between different population groups. For example, differences in hemoglobin concentration between adults and newborn babies or differences in nature and rate of morbidity and mortality in different countries or social classes. Some health inequalities are attributable to biological variations (the hemoglobin example); these are unavoidable. In others, the uneven distribution may be unnecessary and avoidable as well as unjust and unfair, so that the resulting health inequalities also lead to inequity in health.
INDICATORS OF CHILD HEALTH AND DISEASE
Health information produced should be useful, accessible, and appropriate for the various stakeholders. Health indicators are aggregated relevant statistical data pertaining to wellbeing that can be developed for different aspects of health and healthcare. As per WHO an ideal health indicator should be valid (should measure what it is intended to measure), objective (should give same results under same conditions even by different observers), sensitive (should be sensitive to changes in the health conditions), and specific (should reflect changes only in the situation concerned). Here we will primarily focus on the current commonly used indicators.
Stillbirth Rate
It is the number of stillborn infants (after 28 weeks of gestation) related to the total number of births (live and still) during the same period. It is expressed in relation to 1,000 total births.
Perinatal Mortality Rate (PMR)
Number of deaths occurring in the perinatal period (includes stillbirths plus the neonatal deaths occurring in the first 7 days after birth) in a given year to the total number of births (live and still) in the same year. It is also expressed as rate per 1,000 total births. For inclusion in this rate, the stillbirth or live births should be either (1) >1,000 g in weight, (2) >28 weeks in gestation or if (1) and (2) are not available, should measure 35 cm or more in length at birth.
In developing countries, this is defined as:
It is considered a sensitive indicator of maternal health.
Neonatal Mortality Rate (NMR)
It is the number of neonatal deaths in relation to 1,000 live births per year.
Infant Mortality Rate (IMR)
It is the number of infant deaths in a year in relation to 1,000 live births during the same period.
This is irrespective of the fact that some of those infants who died in this year might have been born in the last few months of the previous year.
Postneonatal Mortality Rate (PNMR)
Postneonatal mortality rate can also be expressed as a difference between infant and NMRs.
Child Mortality Rate
It is computed as:
Here 1–4 years mean that the age of children should be ≥1 year and ≥4 years; but not completed 5 years yet.
Under-five Mortality
This is expressed as a sum of infant mortality (<1 year) rate and child mortality (>1 and <5 years) rate.
Crude Birth Rate
This is equivalent to the number of live births reported in a given year per 1,000 of total population at the middle of the year.
It is expressed as rate per 1,000. It is a crude measurement of fertility, because it also takes into account that section of the population which is not of childbearing age, e.g., children and elderly.
Maternal Mortality Ratio
This measures the risk of dying from causes associated with childbirth. The numerator gives the deaths arising during pregnancy or from puerperal causes, i.e., deaths occurring during and/or due to delivery, complications of pregnancy, childbirth, and the puerperium. Women exposed to the risk of dying from puerperal causes are those who have been pregnant during the period. Their number being unknown, the number of life births is used as the conventional denominator for computing comparable maternal mortality ratio (MMR).
Maternal mortality ratio is a pseudo index since the denominator is not the total number of pregnant women at a given time. WHO defines maternal mortality as death at pregnancy or within 42 days of delivery; in some defined areas, a period as long as a year is used.
Maternal Mortality Rate
The number of women who die as a result of pregnancy and childbirth complications per 100,000 women of reproductive age (15–49 years) in a given year.
Physical Quality of Life Index
It is a composite index that combines infant mortality, life expectancy (LE) at 1 year of age and literacy rate. Equal weightage is given to each indicator and resulting Physical Quality of Life Index (PQLI) is measured on a scale from 0–100. The desired goal is to attain a PQLI of 100 (present value in developing countries is 30–50 and in the developed world it is 90–98).
An example showing the calculation of PQLI: Available data shows that the minimum and maximum life expectancies of countries is 25 and 75 years, respectively. Also the upper and lower limits of IMR is 10/1,000 and 250/1,000.
For a country X whose PQLI we want to calculate, we have the following data:
Life expectancy at age 1 year = 60 years, IMR = 50 per 1,000 live births, and basic literacy rate (BLR) is 50%.
Higher the value of IMR, the lower the quality of health status and hence a higher value of IMR has been considered as the lower limit of IMR. Thus we find,
IMR index = 250 − 50/250 − 10 = 200/240 = 0.83
Both these indices are multiplied by 100 and thus we obtain life expectancy index (LEI) as 70 and IMR index as 83.
PQLI = (LEI + IMR index + BLR)/3 = (70 + 83 + 50)/3 = 67.67%
Child Mortality
Global under-five mortality rate declined by 59%, from 93 deaths per 1,000 live births in 1990 to 38 in 2019 (Fig. 2).
Over the last two decades large majority of countries have halved their under-five child mortality and 85 countries have achieved two-thirds reduction during the same period. This indicates uneven distribution of under-five child mortality. However, even with noticeable reduction in child mortality nearly 5.2 million under-five children lost their lives in 2019 alone. These children accounted for nearly 70% of all deaths among children and youth <25 years. On an average 14,000 under-five children died per day in 2019 as compared to 34,000 in 1990. Sub-Saharan Africa accounted for the highest 53% followed by South Asia (27%). Most common causes of death in under-five children were complications arising from preterm birth, birth asphyxia/trauma, pneumonia, congenital anomalies, diarrhea, and malaria as shown in Figure 3. Higher rates of death were seen in severe acute malnourished child. These deaths could have been prevented by providing easy availability and accessibility of basic health services, immunizations, nutrition, and access to clean water and sanitation. Injuries and drowning were the most common causes of death in older children. There has been a paradigm shift of pattern of deaths in older children from infectious diseases to accidents and injuries.
Fig. 2: Levels and trends in child mortality report 2020. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation.Source: UNICEF. (2020). Levels and Trends in Child Mortality. United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME), Report 2020. [online] Available from https://data.unicef.org/resources/levels-and-trends-in-child-mortality [Last accessed August, 2021].
Among under-five deaths maximum deaths were seen in first month of life (47%) followed by infants (28%) and toddlers (25%). Large percentage (80%) of newborn deaths are due to complications related to preterm birth, intrapartum events such as birth asphyxia, or infections such as sepsis or pneumonia as shown in Figure 4.12
Children aged 5–9 years had the largest decline (61%) in mortality over the last two decades. This could be explained by sharp decline in infectious diseases. However, this progress was not seen in neonatal deaths. Around 6,700 newborns died per day in 2019. They accounted for a larger share of under-five child mortality in 2019 (47%) as compared to 1990 (40%). Hence, there is a faster decline in global death rate of children aged 1 month to 60 months compared to neonatal period. If we continue with the present trend over the next decade 23 million 5- to 24-year-old will succumb to illness or injury and 48 million under-five children would die. This prompts us to synergize our efforts to prevent child death. Nearly half of these under-five deaths were seen in newborns. Majority of these newborn deaths can be prevented by high quality antenatal care, skilled birth attendant, institutional delivery, and appropriate postnatal care for mother and baby. A comprehensive approach to bring down neonatal death rate and thereby under-five child mortality is the need of the hour. In India, under-five mortality has reduced from 83.1 deaths (95% uncertainty interval 76.7–90.1) in 2000 to 42 deaths (31.5–45.7) per 1,000 livebirths in 2019-2021, and the NMR decreased from 38.0 deaths (34.2–41.6) to 24.9 deaths (18.0–27.5) per 1,000 livebirths. India has shown a declining trend in under-five mortality, however when compared to rest of the nations it occupies the position of second worst nation after Nigeria as far as under-five child mortality is concerned. India is the only large country in the world where gender differences have been observed in mortality. Survival of boys is more compared to girls with gender differential being 3%. Thus, India needs to address its high under-five child mortality by providing universal health coverage easy availability and accessibility of essential health services adopt innovative approaches to increase access, coverage, and quality of child health services with incorporation of community and facility-based care.
GLOBAL CHILD HEALTH
Global child health refers to widespread health impacts that affect large numbers of children and adolescents across boundaries of geography, time, and culture. It includes the impact on the global ecosystem and other health determinants, such as poverty and genetics. Global health implies a context that includes the whole world and produces its own institutional complexities.
The Achievements
Since the development of first children's hospital “Hôpital des Enfants Malades (French = Hospital for Sick Children)”, in Paris in 1802, pediatrics has extended its scope in clinical practice, and is recognized as an independent discipline. Box 1 enlists the top 10 achievements in the field of pediatrics.
One of the most famous milestones in the history of medicine is the inoculation of children and adults with dried scab material recovered from smallpox patients by variolation technique in 17th and 18th centuries. It was Edward Jenner in 1796 who first vaccinated with smallpox vaccine. Currently, vaccination is available against numerous infectious diseases which led to their sharp decline. Through vaccination, scientists and physicians were not only able to offer protection but eradicated diseases like smallpox globally and poliomyelitis in many countries, including India. About 80% of all the world's children are immunized against the six main vaccine-preventable diseases. Diseases close to being eliminated or eradicated include polio, leprosy, neonatal tetanus, guinea worm infestations, and Chagas disease. The latest is development of coronavirus disease 2019 (COVID-19) vaccine which is one of the most important preventive measures in the fight against COVID.
The fact that breastmilk is best for an infant is known from antiquity. However, it was in 1981 that WHO and United Nations Children's Fund (UNICEF) brought the International Code of Marketing of Breast Milk Substitute. It was gradually adopted with modifications by many countries including India. Exclusive breastfeeding for the first 6 months of life has shown immediate and long-term advantages in prevention of infections, adult diseases, and food allergy. Well-baby clinic means that mother and child should be seen as a pair in clinics and not individually. Way back in 1892, Pierre Robin stimulated mothers to bring their healthy infants for weighing. Concept of Road to Health Card was introduced in 1974 by David Morley. It helped to identify growth faltering in children at the earliest. Today, under-five clinics and well-baby clinics are norms offering inclusive preventive advice on infant care, feeding, immunization, growth, and development.
Survival of low birth weight babies, extremely premature infants has necessitated prompt recognition of developmental and other deficits. The term Behavioral Pediatrics was coined and defined by Friedman. It is as “an area within pediatrics which focuses in psychological, social, and learning problem of children and adolescence.” There is multidisciplinary team approach with pediatrician, developmental pediatrician, therapists, speech therapist, and others. Specialists in this area investigate and manage communication delays, autism, attention-deficit disorders, and other learning disabilities that require early diagnosis and intervention.
Oral rehydration therapy (ORT) in diarrhea has been able to prevent more deaths occurring annually worldwide, than any other treatment modality. This “simple solution” has resolved a monumental problem and saved millions of lives till date. However, about 8,000 children still die each day from diarrheal dehydration, a toll which the clinicians can and must strive to reduce.
United Nation convention on Rights of the Child was passed as an International declaration in 1990. The rights of the child declaration confers rights for a life with dignity, protection from exploitation, and rights to education, love, play, be the first to get help, have a name and family, etc.
Although genetics emerged as a specialty about half a century ago it was pediatricians who took lead in this field because of their recognition of genetic disorders, syndromes, and malformations in children. As of now genetics has emerged into a specialized subject and has expanded to prenatal screening of diseases, cytogenetic, molecular genetics and in diagnosis of several disorders including asthma, growth failure, hypertension, and diabetes type 2.
The development of genomics was the natural progression of research in genetics. From single gene identification to the formation of Human Genome Project and finally to mapping of the Human Genome in 2003. Its application to pediatrics is similar to genetics and for population studies. Proteomics coined in 1994, seeks to investigate protein functions as it relates to its environment and biological setting. It will lead to development of new drugs and biomarkers. Metabolomics derives its name from “Metabolome” a term used to describe collection of metabolites in body fluids, tissue organs, and biological cells. It is likely to help detection of diseases, classify patients based on biochemical profiles, and monitor disease progress.
Bioinformatics play a critical role in understanding the molecular basis of diseases, identifying markers for disease predisposition, diagnosis and prognosis of disease, and help in developing better vaccines and therapeutics. In future bioinformatics is going to play a major role in reducing neonatal and child morbidity and mortality.13
With advent of ultrasonography many fetal developmental anomalies are picked up in antenatal life. This has led to the development of new branch called fetal medicine and surgery. Fetal surgery is possible either by minimal or major surgical intervention. Minimal surgery is by fetoscopy used for fetal transfusion, bladder neck obstruction, and certain congenital heart ailments. The major fetal surgery is now available for neural tube defect and diagrammatic hernia, through a cesarean section.
The last few decades have witnessed tremendous advances with new knowledge being accumulated in the fields of physiology, biology, immunology, and in the development of new drugs. It is now possible to prevent the progress of various diseases before they seriously damage the health of an individual. Several genetic disorders and inborn errors of metabolism are better understood, and several of these can be detected by screening pregnant mothers and newborn infants. Fetal malnutrition is recognized as the programing event for several noncommunicable diseases (NCDs) in the adult life. Nutritional interventions through diet and micronutrient administration in pregnancy may help in preventing a staggeringly high incidence of these disorders. Childhood sexual abuse, juvenile delinquency, and adolescent violence can be prevented by promoting harmony between parents, children, and between siblings. Injuries can be prevented by greater awareness in community and better designs of the incriminating agent.
The Challenges
Despite an encouraging progress with respect to certain health indicators globally, there are still wide differences in health status between and within countries. Achieving equity in health and sustaining the efforts to ensure that the world's most vulnerable people have access to health services are the most formidable global health challenges today.
Increasing Population
Current world population is 7.9 billion (2021). India has a population of 1.39 billion (2021). This exponential increase in population is increasing the burden on the demands of healthcare resources.
High Maternal Deaths
Even though maternal deaths are preventable and there has been steady decline in maternal deaths worldwide, still in 2013 there were 2.89 lakh maternal deaths globally. The difference in MMR, between the richest and poorest countries is quite high. The lifetime risk of maternal death in industrialized countries is 1 in 4,000, versus 1 in 51 in countries classified as “least developed.” The predominant causes of maternal deaths are the direct obstetric causes namely; hemorrhage (27%), hypertensive diseases of pregnancy (14%), and sepsis (11%).
Large expansions in antenatal care coverage are still needed as only 64% of pregnant women received the recommended minimum of four antenatal care visits or more. In addition, despite increasing coverage of delivery by a skilled birth attendant both globally and in several regions, coverage is still only 51% in the WHO African Region and in low-income countries.
High Child Mortality
The world has achieved progress in child survival in the past three decades, and millions of children have had better survival chances as compared to two decades ago. There is marked progress in reducing child mortality rates over last two decades with the annual rate of reduction in the global under-five mortality rate increasing from 1.9% in 1990–1999 to 3.7% in 2000–2019. Detailed discussion is provided under the heading child mortality.
Infectious Diseases
Globally, an estimated 3.2 billion people are at risk of being infected with malaria and developing disease, with 1.2 billion at particularly high risk (greater than a one-in-thousand chance of getting malaria in a year). The population at risk of contracting malaria has increased by 32.5% globally and by 43% in Africa. According to the latest estimates, 229 million cases of malaria occurred globally in 2019 and the disease leading to 409,000 deaths.
1.4 million people died from tuberculosis in 2019, including 208,000 people with human immunodeficiency virus (HIV), and major efforts will be required to ensure that all cases are detected, notified, and treated. 206,030 people with multidrug- or rifampicin-resistant TB (MDR/RR-TB) were detected and notified in 2019.
For dengue—the world's fastest growing arboviral infection—effective, long-term vector control and disease-prevention measures (including future vaccines) will require strong and well-funded national programs and strategies, and the support of partners in the global public health community, to reduce morbidity and mortality by 2020.
Emerging and re-emerging infectious diseases such as Ebola, H5N1 viruses, Cholera, and Middle East respiratory syndrome coronavirus (MERS-CoV) infections are other global health issues that will need serious global attention to control it.
Noncommunicable Diseases
Noncommunicable diseases kill 41 million people each year, equivalent to 71% of all deaths globally. Almost three quarters of all NCD deaths (28 million), and 85% of the 15 million premature deaths, occur in low- and middle-income countries. NCDs amount to 15 million people dying prematurely—before the age of 70 years—from heart and lung diseases, stroke, cancer, and diabetes, according to a new WHO report.
Access to Water and Sanitation
In 2017, 71% of the global population (5.3 billion people) used a safely managed drinking-water service—that is, one located on premises, available when needed, and free from contamination. A staggering 2 billion people have no access to toilets, latrines, or any form of sanitation facility at all and therefore practiced open defecation. 785 million people lack even a basic drinking-water service, including 144 million people who are dependent on surface water. Lack of sanitation facilities puts these people at high risk of diarrheal diseases (including cholera), trachoma, and hepatitis. In addition, wide disparities continue to exist, not only between different regions of the world but also between urban and rural areas and between different socioeconomic groups within countries.
Health Expenditure
Before the COVID-19 pandemic, global spending on health continued to rise, albeit at a slower rate in recent years. 2018 was the first year in 5 years in which global spending on health grew slower than gross domestic product (GDP). US tops the list of countries spending on health at 16.9% of GDP. India is way below and finishes at second from the bottom of the list with 3.6% in the year 2018. More formal financial transfers to protect those too ill to work are less common. Only one in five people in the world has broad-based social security protection that also includes cover for lost wages in the event of illness, and more than half the world's population lacks any type of formal social protection, according to the International Labour Organization (ILO).
Increasing Years Lived with Disability
Aging of the world's population is leading to a substantial increase in the numbers of individuals with sequelae of diseases and injuries. 14Rates of years lived with disabilities (YLDs) are declining much more slowly than mortality rates. The nonfatal dimensions of disease and injury will require more and more attention from health systems. The transition to nonfatal outcomes as the dominant source of burden of disease is occurring rapidly outside of sub-Saharan Africa. Leading causes of YLDs included low back pain and major depressive disorder among the top ten causes of YLDs in every country. YLD rates per person, by major cause groups, indicated the main drivers of increases were due to musculoskeletal, mental, and substance use disorders, neurological disorders, and chronic respiratory diseases; however HIV/AIDS was the main reason for the increasing YLDs in sub-Saharan Africa. Also, the proportion of disability-adjusted life years (DALYs) due to YLDs increased globally from 21.1% in 1990 to 31.2% in 2013. DALYs due to communicable diseases such as HIV/AIDS and diarrheal diseases have reduced by 50% since 2000. DALYs from diabetes accelerated by >80% between 2000 and 2019. DALYs from Alzheimer's disease have more than doubled between 2000 and 2019. Emerging health issues for the future are emerging diseases like Ebola, COVID-19, antimicrobial resistance development, climate change impacts, and shortage of skilled health manpower.
CHILD MORBIDITY
There has been a remarkable progress in child mortality. However, both children and adolescent still suffer from significant challenges in surviving and developing to their full potential. Over the last two decades there has been a change in epidemiology of global child health with better control of infectious diseases and changes in social life. Now noncommunicable illnesses and injuries are on the rise. At present the most common child morbidities are congenital anomalies, injuries, and NCDs (chronic respiratory diseases, acquired heart diseases, childhood cancers, diabetes, and obesity). Age-wise distribution of child morbidity is shown in Table 1.
Neonatal Period
With improving maternal and newborn healthcare services there has been a significant decline in global number of newborn deaths from 5 million in 1990 to 2.4 million in 2019. However, even now children face the highest risk of death in their first month of life. Thus, we need to concentrate and invest on the greatest burden of deaths and disability in this age group to bring about the desired results in a child's health. Efforts taken in providing efficient antenatal, natal, and postnatal health care will go in a long way in saving life of mothers, newborns, prevent stillbirths, reduce disabilities and pave the way for optimal child development. Common morbidities in this age group are shown in Table 1.
Low Birth Weight
Low birth weight babies are babies with birth weight <2.5 kg. In 2015, globally 20.5 million low birth weight babies were born. On an average nearly 70% of world's low birth weight babies are born in developing countries. These babies are more likely to die in their first month of life and account for nearly 10% of neonatal mortality. Hence, if we provide better care to this group of babies we will be able to curb the NMR. Further long-term complications like diabetes, hypertension, and obesity are seen more commonly in low birth weight babies as compared to those babies with normal birth weight. Aim of World Health Assembly (WHA) on nutrition target was to decrease the prevalence of low birth weight to <30% by 2025. However, attainment of this reduction has been limited in all regions of the world. Globally the annual average rate of reduction (AARR) in low birth weight prevalence was only 1.2% between 2000 and 2015 as against desired rate of 2.74%. There is no apparent change in low birth weight prevalence in Latin America, Caribbean Island, and Western Europe. On the contrary, there has been slight increase in prevalence of low birth weight babies in North America from 7.3% in 2000 to 7.9% in 2015.
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Prematurity
Prematurity is defined by WHO as birth of baby before 37 weeks of pregnancy. It is not only the foremost cause of neonatal deaths but now it has also become one of the most important cause of death in under-five children. Globally, each year, 15 million preterm babies are delivered which accounts for 11% of all deliveries. In India, it accounts for nearly 13% of all deliveries. Survival of these preterm births have improved in developed nations but their survival in middle- and low-income countries is still dismal.
Birth Asphyxia
Birth asphyxia is defined as a failure to initiate or sustain spontaneous breathing at birth. Globally 2.5 million newborn deaths are due to birth asphyxia. First day and especially the first hour of birth is critical for survival. Skilled birth attendant at time of delivery and proper postnatal check-ups are crucial for wellbeing of mother and child. Nearly 17% of deliveries were not attended by skilled birth attendants in 2020.
Sepsis
Defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. 1.3–3.9 million annual neonatal sepsis cases are reported globally with 400,000 to 700,000 annual deaths worldwide. In institutional deliveries an estimated 4–56% of all deaths occurred in the neonatal period due to hospital-acquired sepsis. About 84% of these deaths could have been prevented by early diagnosis and timely treatment. Highest number of neonatal sepsis was seen in low-income countries particularly the African region. Group B Streptococcus and Escherichia coli infections accounted for 70% of early-onset neonatal sepsis.
Congenital Malformations
There has been an exponential increase in frequency of congenital anomalies with 1 in 33 infants being affected leading to 3.2 million children with disabilities due to birth defects every year.
Children Aged 1–5 Years
Children <5 years of age are particularly susceptible to infectious diseases like malaria, dengue, tuberculosis, HIV, pneumonia, and diarrhea. Despite being preventable illness, diarrhea, pneumonia and malaria are still responsible for 29% of global deaths in under-five children. Children living in low-income group countries like sub-Saharan Africa are worst affected. Poor socioeconomic status and illiteracy contribute to high burden of infectious diseases in developing countries. These risk factors are major determinants of undernutrition, infectious diseases, gender inequity, child labor, and child abuse. Although diarrheal disease is both preventable and treatable, it is the second leading cause of death in under-five children. Each year diarrhea kills 525,000 under-five children. 15Majority of these deaths could have been averted by provision of safe drinking-water, adequate sanitation, and hygiene. Globally, there are nearly 1.7 billion cases of childhood diarrheal disease every year. Diarrhea is also single most leading cause of malnutrition in under-five children. If it lasts for several days, it leads to salt and water loss causing severe dehydration which is the main cause of diarrhea deaths. Malnourished children have impaired immunity which predisposes them to severe infections. Worldwide, 780 million individuals lack access to improved drinking-water and 2.5 billion are deprived of proper sanitation. Diarrhea due to infection is widespread across developing countries. Children under 3 years living in low-income countries suffer from an average three episodes of diarrhea per year. Each episode of diarrhea predisposes a child to malnutrition.
Malnutrition
It refers to deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients. It can be of two types: undernutrition which includes wasting, stunting, underweight; or obesity. Both types predispose a child to diet-related NCDs. Globally in 2020, nearly 149 million under-five children were estimated to be stunted, 45 million were estimated to be wasted and 38.9 million children were overweight or obese. Malnourished children are more prone to infections particularly diarrhea and pneumonia.
Pneumonia
It is an important cause of under-five child morbidity and mortality. It accounts for 15% of deaths in under-five children killing nearly 808,694 children in 2017. It is an important vaccine-preventable illness, and it can be treated by antibiotics even then it is killing a child every 39 seconds. Pneumonia and diarrhea together are the major causes of under-five children mortality and account for 29% of deaths leading to loss of 2 million young lives. Low-income group countries in sub-Saharan Africa and South Asia account for 90% of under-five deaths due to diarrhea and pneumonia. Causes and solutions for both diarrhea and pneumonia are interrelated hence an integrated action plan for diarrhea and pneumonia [Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD)] was developed by WHO to end preventable child deaths from diarrhea and pneumonia.
Malaria
It is another important cause of under-five child morbidity and mortality killing a child every 2 minutes. Deaths due to malaria in under-five children accounted for 67% of global malaria deaths. WHO has initiated WHO Global Malaria Programme (GMP) to control and eliminate malaria. Over last two decades, 21 countries have eliminated malaria and 11 have been endorsed malaria-free by WHO.
Tuberculosis
It claims lives of nearly 600 under-15 children every day with majority of deaths being seen in under-five children. Countries have developed national programs for prevention, surveillance diagnosis, and treatment of tuberculosis, yet 1 million children are falling ill every year. Off these 1 million children only 50% are identified and registered by national programs. WHO has announced End TB strategy. The most important road map to achieve it is prevention, appropriate diagnosis, and management of childhood tuberculosis. Apart from tuberculosis another important communicable illness in under-five is HIV infection. Both HIV and tuberculosis are seen more commonly in undernourished children. They affect similar populations in resource-limited settings and predispose the child to persistent diarrhea and other opportunistic infections further deteriorating their nutrition status. Each day approximately 880 children are getting infected with HIV virus and 310 children are dying due to AIDS-related cause. Majority of these children (90%) live in sub-Saharan Africa. However there has been a bright spot in childhood HIV, with the launch of nation wise programs to prevent mother to child transmission which has brought about rapid decline in number of new cases in children <5 years.
Adolescents
Survival chances of children aged 10–14 years vary in different regions of the world. It is worst in sub-Saharan Africa, Central and South Asia, Latin America, and Caribbean Islands. Probability of a 10-year-old dying in sub-Saharan Africa is 10 times as and when compared to high-income countries like North America and Europe. Nearly 1.5 million adolescents or 5,000 adolescents per day lost their life in 2019. Major causes of mortality in them were injuries, violence, substance abuse, early pregnancies, unsafe abortions, etc. Globally on an average 43 per 1,000 girls aged <18 years of age are giving birth per year.
Injuries
Inadvertent injuries are the foremost cause of death and disability among adolescents. Road Traffic Accidents stands out as a major killer in the year 2019. Majority of the victims were vulnerable road users like amblers, cyclists, or drivers of two wheelers. Many countries still have not enforced road safety laws and more and more young drivers are coming up on the roads. Furthermore, lack of safety equipment like helmets, use of safety belts, or driving under the influence of drugs or alcohol has worsened the outcome. Graduated licences for novice drivers is essential and should be enforced by the law of the land. Drowning is another important cause of adolescent deaths. More than 30,000 adolescents, particularly boys, have died due to drowning in the year 2019. Children should be taught and monitored while swimming to prevent these deaths.
Violence
Fourth leading cause of adolescence death is interpersonal violence. Low-income countries have a higher prevalence of deaths due to violence in adolescent males. Sexual violence too accounts for significant proportion with 1 in 8 reporting sexual abuse. This also increases the risk of HIV, sexually transmitted infections, mental health, early pregnancy, and early school dropouts. Proper parenting, early childhood development (ECD), community participation, sexual education, restriction on alcohol consumption, and law enforcement are the keys to reduce violence and its consequences.
Mental Health
Mental health particularly depression is one the foremost causes of disability in adolescents. It accounts for nearly 16% of global burden of diseases. Suicide is the third leading cause of death in children aged 15–19 years. Children as young as 14 years start showing symptoms of depression. Factors associated with poor mental health are violence, poverty, social stigma, exclusion, lack of education, parental divorce or separation, and living in fragile settings. If the mental health is unaddressed at adolescence, these children will grow up with limited opportunities of living a fulfilling life in adulthood. In order to address and prevent this disability children should be taught socioeconomic skills early in life. Every effort should be made at individual and at community level to strengthen ties between adolescents and their families.
Alcohol and Substance Abuse
Drinking alcohol and substance abuse is a major health issue for adolescents both in developing and developed countries. Driving under its influence is one of the major causes of road traffic accidents. 16155 million adolescents globally have started consuming alcohol below the legally permitted age. Prevalence of heavy episodic drinking among adolescents aged 15–19 years was 13.6% in 2016, with males most at risk. The most used psychoactive drug in adolescents is cannabis (4.7%) in 2018. Neurocognitive alterations due to substance abuse lead to behavioral, emotional, social, and academic problems in later life. Countries have developed programs for prevention of use of alcohol and drug by incorporating population-based strategies interventions, activities in school, community, family, and on the individual level. Legal system of each country has a set minimum age for consumption of alcohol. Drug consumption is banned in all countries with strict punishments for its perpetrators.
Tobacco Use
Tobacco smoking is prohibited in many countries of the world yet 1 in 10 adolescents aged 13–15 years are smoking tobacco.
HIV/AIDS
1.7 million adolescents aged 10–19 years are living with HIV in the year 2019 with a significant majority (90%) living in WHO African region. 1994 saw a peak in the number of new cases thereafter there has been a substantial decrease in fresh cases. However, adolescents account for 10% of new adult HIV infection. Early onset of sexual behavior, lack of use of protective measures, poverty, broken families, and lack of education are key contributing factors.
Other Infectious Diseases
Improved vaccination coverage has helped in decreasing death and disability due to vaccine-preventable illness. For example, adolescent mortality due to measles has decreased by as much as 90% in African region over the last decade. Diarrhea, pneumonia, and meningitis still account for the most important causes of morbidity in adolescents aged 10–14 years. Human papilloma virus infection is another vaccine-preventable illness which is becoming common in adolescents. It is normally seen after a sexual activity and can lead to both short-term disease (genital warts) or more severe cervical cancer in later age. HPV vaccination has been advised at early adolescence (9–14 years). Even then by 2019 globally only 15% of girls have received it.
Early Pregnancy and Childbirth
Early age of sexual activity and teenage pregnancy are on the rise leading to death in girls aged 15–19 years due to pregnancy-related complications. 12 million girls aged 15–19 years and 777,000 aged under 15 years are getting pregnant per year. Global adolescent birth rate in 2020 was 43 births per 1,000 girls. Universal access to sexual and reproductive healthcare services, family planning programs, sexual education, better access to contraceptive measures, strict law enforcement regarding minimum age of marriage, and safe access to abortion is the need of hour.
Nutrition and Micronutrient Deficiencies
Anemia particularly iron deficiency is an important cause of adolescent morbidity. Many countries like India have started nation-wise iron folic acid supplementation and regular deworming to prevent micronutrient (including iron) deficiencies. Good eating habits is foundation of good health. There should be regulatory laws to stop promotion of food which are high in saturated fats, trans fatty acids, free sugar, or salt.
Decreased Physical Activity, Undernutrition, and Excess Screen Time
With advent of latest technology and ever-expanding digital media there has been an increase in duration of screen time. This has led to with restriction of outdoor physical activity. With the ongoing COVID pandemic the situation has worsened. Obesity is on the rise leading to increased prevalence of noncommunicable illness in adolescents. Globally in the year 2016 nearly one in six adolescents were overweight. Prevalence varied in different regions of the world from 10% in South-East Asia to over 30% in America. WHO had recommended at least 60 minutes of physical activity daily. Globally only one in five adolescents meet these guidelines. Frequency of slothfulness is high particularly in female adolescents as and when compared to male adolescents.
EARLY CHILDHOOD DEVELOPMENT
Early childhood years from conception to 6 years are the most fundamental period in a child's life which lay the footing for further learning and development. Brain growth is maximum in the initial years with 90% being in first 6 years. Millennium year had brought remarkable progress in poverty reduction in developing countries yet children in those countries were still lacking from reaching optimum development and wellbeing. This could be due to limited access of children to health services, poor nutrition, and poor psychosocial development. It is the effective nurturing of child's initial years that will decide the fate of his rest of his life. It is seen that the most disadvantaged children are the ones to have least access to health care. Prolonged exposure to stress (both physical and mental) would trigger inappropriate biological responses which would interferes with development of brain. This would contribute to a vicious cycle of poverty, inequality, and social exclusion. Nearly 250 million under-five children living in low- and middle-income countries are not able to reach their developmental potential due to extreme poverty.
Child's health begins right after conception. Maternal health, nutrition, and environment would impact on her baby's growth and development. After birth, initial years of his life would be the foundation stone for his physical and mental health. The building blocks of a child's life remarkably depend on his foundation. Hence, getting the foundation right is the most important direction toward which countries health policy should concentrate. Numerous factors influence early child survival outcomes, but an important share is attributable to health service provision and the social determinants of health. Maternal care, namely availability of prenatal care, medically-assisted deliveries and institutional deliveries significantly reduces infant mortality. Other factors associated with infant and child mortality include poverty, location (urban/rural), access to electricity, and caregivers’ level of education. Despite the need of ECD there is little urgency shown by governments across the world. For example countries like sub-Saharan Africa, only 0.012% of gross national product is spent on preprimary education.
To provide ECD opportunities for children to survive thrive multisectoral involvement of health nutrition and early learning is required. UNICEF has adopted the global program on ECD which concentrates on early years of child. Objectives of the program for both child and his parents or care givers are enumerated below:
- Essential services for children up to age of school entry: Equitable access to quality child care, health, nutrition, protection, and early learning services to address their developmental needs.
- Nurturing care by parents or care givers: Enforces on positive parenting, stimulation, and learning. Nurturing care framework (Fig. 5) has been described for every child so as to help them to reach their full potential. It comprises of five inter-related and indivisible components such as good health, adequate nutrition for mother and child, security and safety, responsive care giving, and early learning.
Nurturing care of a child starts even before conception. Healthy and happy mothers give birth to healthy babies. It reduces chances of prematurity, low birth weight, and congenital disorders. Mothers can communicate with their fetus by about second trimester of pregnancy when the growing fetus begins to hear. After birth early skin to skin contact and exclusive breastfeeding helps in growth, optimal nutrition, and care of the newborn.17
Fig. 5: Components of nurturing care.Source: World Health Organization, United Nations Children's Fund, World Bank Group. Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. Geneva: World Health Organization; 2018.
For preterm babies nurturing care is particularly important as these babies are vulnerable. It is imperative for caregivers and health professionals to provide adequate care to both mother and child and create a supportive environment for their optimal development. Other factors that compromise ECD include poverty, poor maternal nutrition, exposure to environmental pollutants, toxic chemicals, poor mental health in caregivers, inadequate breastfeeding, malnutrition, recurrent infections, chronic illnesses, unintentional injuries, poor stimulation, neglect, maltreatment, disabilities, gender differentiation, and unstable home. In developed nations emerging problems are early parenthood, substance abuse, maternal depression which have negative impacts on ECD. In low- and middle-income countries poverty is an important cause of suboptimal development and stunted growth. War, disaster, and displacements have impaired the lives of millions of children globally. 250 million children are staying in war affected countries another 160 million are residing in country suffering from food crisis due to prolonged famine, water depletion. Two percent of humanitarian funding is allotted for child's education and development but a very minimal portion is spent on ECD. Children are the future of the world, and we urgently need to integrate the Nurturing Care Framework into humanitarian policies, programs, and services for the upliftment of children.
Good Health
For children to have good health, parents or caregivers should monitor their physical and emotional conditions, provide affectionate response to their daily requirements, protect them from dangers both inside and outside their homes, practice hygiene, and provide early and appropriate treatment for their illness. To provide good health, the care giver too should be physically and mentally fit. Thus, it is a vicious cycle of healthy parents and healthy children.
Adequate Nutrition
Parents have a duty to provide healthy nutrition to their offsprings. This begins right from conception. Healthy mothers bear healthy fetus and would be able to exclusively breastfeed her child. Infant's brain growth depends a lot on the nutrition he receives. Thus, exclusive breastfeeding for 6 months followed by introduction of nutrient enriched complementary feeds are key criteria in the initial stages of child brain and physical growth. Besides healthy diet social and emotional interaction involved in feeding a young child too have a significant role to play. Both food safety and family food security are essential for adequate nutrition.
Responsive Caregiving
Infants until they develop speech, try to communicate with their parents or caregivers through movements, eye contact, sounds, and gestures. It is impertinent for caregivers to recognize them and react to them to protect them from adversities, illnesses, and help them to learn and build social relationships.
Opportunities for Early Learning
Learning starts right from conception. Initially described as epigenesis a biological mechanism. It then continues through infancy when motor and fine skills are obtained from the environment a child is placed in. For example, through touch feel of simple household objects like cups, plates, and spoons a child can decipher shapes, learn colors provided the caregiver is interacting and motivating the child.
Security and Safety
Young children need protection at home and outside their homes as they themselves cannot anticipate dangers. Children <5 years are hyperactive and are prone to poisoning, foreign body aspiration, and injuries. They can encounter fear from strangers, feel uncomfortable when left alone. They are prone to both physical and sexual abuse. These experiences give rise to overwhelming fear and stress thereby leading to emotional and social alienation.
Aim of nurturing care is to make a child safe and secure, allow him to bloom to his full developmental potential.
ECD and COVID-19
The ongoing pandemic of COVID-19 has given rise to new set of challenges for parents and caregivers. With closure of schools, development of new modes of online teaching, restricted movement of children, less interaction with peer groups, and the daily lives of the little ones have changed. In addition to it parents are suffering from job loss, social insecurities in addition to added responsibilities of interacting to a greater extent and spending quality time with their children.
CHILD LABOR
Globally in the year 2020, 160 million children were being subjected to child labor. COVID-19 has increased the susceptibility of additional 9 million children. Thus, by the end of 2021, 1 in 10 children would be driven to child labor and almost half of them would be working in perilous state endangering their health and development. Broken families, poverty, overpopulation, unemployed parents, and death of parents or caregivers are pushing children into child labor and their numbers are increasing day by day. The aftermaths are astounding leading to physical harm, mental harm, or death. Children are deprived of their fundamental rights of schooling, health care, and often subjected to undue stress and sexual exploitation. Current pandemic with increasing economic insecurities, political and social instability is leading to adverse socioeconomic and financial impact which has given rise to a large migrant population and refugee children. Nearly 30 million children are living outside their country of birth. These children are neither protected by law of the land or any government bodies and are easily available for menial works at reasonable cost. Sometimes these children are illegally trafficked 18for sexual exploitations, or they become subjects of illegal organ donation. Attempts by WHO and UNICEF to stop child labor has been hindered over since 2016 and with rising armed conflict and unstable geopolitical scenario there has been a rise in the incidence of hazardous work by children living in these countries by about 50% as compared to global average. UNICEF along with ILO has emphasized on birth registration. This would ensure governments to enforce minimum age of work and help to remove children from labor to schools. Population control, increased work opportunity, parental education, and comprehensive social services would help in the long run to keep a child protected and within his family.
VIOLENCE AGAINST CHILDREN
Child abuse implies to all aggression against any child under 18 years of age inflicted by parents, caregivers, or strangers. Globally, year 2019 saw nearly 1 billion children aged under 18 years suffering from abuse physical, sexual, or emotional. Consequences of child abuse have long lasting effects on physical and mental wellbeing. Exposure to violence in early years impacts health and wellbeing of a child. 2030 agenda for Sustainable Development is to end abuse, exploitation, trafficking, and all forms of violence against children. Maltreatment can occur at any stage of a child's life. It can be physical, sexual, psychological, or emotional. Perpetrators can be parents, care givers, friends, and neighbors. Setting can be either at home, school, orphanage, etc. Schools and playgrounds can be a perfect place for bullying or harassing. Bullying can be physical, mental, or social. Nowadays in a world of digital media cyber bullying is on the rise. Adolescents (males or females) can be victims of intimate partner violence. However, it is seen more commonly in adolescent unmarried females. She can be a victim of sexual abuse including online sexual harassments. Impacts of these abuses can be multidimensional. It could lead to death (homicide, suicide) or injuries. If the assault occurs at a younger age, there is negative impact on the cognitive development of child due to impaired development of brain and nervous system. Recurrent exposure to physical and mental abuse would later lead to anxiety, depression and eventually to substance abuse high-risk sexual behavior, unintended pregnancies, abortions, sexually transmitted infections, and HIV.
Violence against children is preventable. WHO has developed the word INSPIRE where each word stands for a strategy. I for implementation and enforcement of law, N for norms and value change, S for safe environment, P for parental and caregiver support, R for response service provision, and E for education and life skills. Children are the future of tomorrow, and it is their right to grow up in a safe and secure environment. It is the duty of parents, caregivers, health workers and policy makers to ensure that they are provided one.
To conclude, the world has undergone remarkable progress in young child survival over the past two decades. Declining global child mortality particularly under-five mortality is an indicator of better coverage of essential health services, health system readiness, and better implementation of child health policies. Despite this progress there are certain gray areas which need to be addressed. Reduction in child mortality is not uniform, countries in sub-Saharan Africa still account for 50% of global under-five mortalities. Rate of reduction in neonatal mortality is still slow and accounts for nearly half of under-five child mortality. Prematurity, birth asphyxia, diarrhea, pneumonia, and vector-borne diseases remain as the most common cause of under-five child mortality. For adolescents, road traffic accidents, injuries, drowning, and burns are leading causes of mortality and morbidity. Gradually, the focus of child health is now shifting from child mortality to nurturing care and provision of better environment for development and growth of child. It is a known concept that an adolescents physical and mental health would depend on the care he receives in his initial life. By improvising the environment and concentrating on a child's physical and mental health in his initial years would pave the way for a healthy nation and a healthy world.
1.3 Evidence-based Care in Pediatrics
Joseph L Mathew
In recent years, the term evidence-based medicine (EBM) has transformed from an esoteric academic concept to a practical process of enhancing healthcare delivery. Over the past two decades, resistance among physicians and other healthcare providers to this facet of clinical practice has gradually diminished. The term EBM itself has been widened to evidence-based practice or evidence-based healthcare, although many experts prefer to use the more neutral phrase “evidence-informed” rather than evidence-based. Whatever term is used, broadly it refers to the scientific discipline of incorporating research and clinical evidence into healthcare decisions and practice. For want of a more specific definition, evidence-based pediatric care can be taken to include the principles, processes, and practice of EBM for the health and wellbeing of children.
WHAT IS EVIDENCE-BASED HEALTH CARE?
Excerpts from some of the definitions of EBM during the evolutionary years, help to clarify the concept and (perhaps more important) the scope of EBM (Table 1).
For practical purposes, the 1998 description of EBM as the “integration of good evidence with clinical expertise and patient values” by Strauss and Sackett, is simple yet elegant. It captures the importance of clinical expertise as well as research-based evidence, the two concepts that are sometimes in conflict. The third dimension of “patent values” emphasizes that healthcare delivery is not a mechanical process, but centered around the key stakeholder, viz., the patient. It also highlights that clinical decisions and actions are to be individualized, besides the fact that clinical (and other healthcare) decisions are to be shared by healthcare providers and recipients.
At this point, it is very important to also understand, what is not evidence-based care. The blind application of the results or conclusion(s) of research publications (such as systematic reviews or other types of research) into clinical practice is one common mistake. Likewise, selective identification and utilization of research papers to support or justify whatever a professional is doing (or prefers to do), also does not constitute evidence-based care. Further, interpretation (and application) of data selectively (i.e., without understanding the full context) is also inappropriate. Ignoring the values, preferences, and wishes of patients by not involving them in decisions concerning their health, is a serious violation of the principles of evidence-based care.
Other misconceptions about EBM are that its purpose is to make the practice of health care more democratic, in the sense that, professionals with and without vast experience or expertise are at the same level of subservience to research evidence. This is completely erroneous as the definition itself emphasizes the need for clinical expertise, in order to practice evidence-based care. Some professionals mistakenly believe that the main application of EBM is to judge whether interventions that work in developed country settings can be applied to local settings; while others feel that evidence-based care reduces the need for clinical judgment as all children with a given clinical condition could be treated with a uniform protocol.
Strictly speaking, the term evidence-based may be a misnomer because it implies that there is a scope for nonevidence-based practice as well. However, in fact almost all healthcare professionals use some kind of evidence for their clinical decisions and it is unlikely that anyone acts solely on personal whims. However, there is wide latitude in what constitutes evidence, and even more dissent about what constitutes best evidence. All professionals would agree that evidence is based on observations in the clinical and research setting, and that greater the number of observations pointing in a given direction, the more likely (though not necessary) that it points toward the truth. However, best evidence creates controversy. Many professionals argue that their personal experience and clinical observations constitute the best evidence for their patients (and practice setting). However, the traditional evidence hierarchy places expert opinion right at the bottom of the pyramid (Fig. 1), even below case reports of individual patients. But, the definition of EBM insists that clinical expertise is a significant component. This apparent paradox can be resolved by understanding that the quality of evidence (and its categorization as good, better, or best) is in proportion to the efforts made to remove or resolve bias from the process of generating and/or interpreting the observations comprising evidence. The term “bias” reflects anything which leads investigators away from the truth. In research methodology, it represents a systematic error due to limitations in methods and procedures used to conduct the research study. It is to be distinguished from random error whereby research investigators may be led away from the truth purely due to chance, hence it is an error outside their control.
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It is for this reason that any form of evidence having a low(er) risk of bias climbs upward on the evidence hierarchy and vice-versa. This is precisely why randomized controlled trials (RCTs) of interventions and systematic reviews of RCT are ranked highest in the evidence hierarchy. Among systematic reviews, Cochrane reviews are superior on account of methodological rigor, multiple quality-control processes at various stages, and a robust peer review as well as editorial process.
Patient values include the unique circumstances (such as healthcare setting, personal or social issues, economic status, etc.) of individual patients, for and (hopefully) by whom, healthcare decisions are made. In a well-developed healthcare system (unlike the provider-driven settings in most developing countries), patients, i.e., consumers of healthcare are provided the professional's judgment (based on clinical expertise) and the best evidence (based on relevant research and the experience in that healthcare setting); and they are encouraged to make decisions factoring in their perception, situation, and expectations. The role of the professional is to facilitate this process and guide patients in the right direction, addressing their concerns. Ideally, this is how evidence-based care is to be practiced. Therefore, it may happen that while professional judgment and research evidence point in a certain direction, the patient may choose not to take that direction on account of his or her values. Such situations are to be respected by healthcare professionals. When such a decision is a shared process between the patient and the professional then it too constitutes evidence-informed practice.
EVIDENCE-BASED PRACTICE
A detailed description of how to practice evidence-based healthcare is outside the scope of this chapter. Readers may access the large number of resources freely available through the internet. A brief outline of the steps involved in evidence-based practice is presented in Table 2.
It should be clearly recognized that evidence is a tool to facilitate appropriate decision-making and is not the decision itself. A parallel can be drawn from the various laboratory tests ordered by healthcare professionals. Good physicians use the results of laboratory tests to confirm what they suspect on the basis of their knowledge and clinical expertise. They also factor in the circumstances of an individual patient and the local healthcare setting. They would not base their decision(s) solely on the basis of the test results no matter how impressive they may be. This is how evidence is expected to be used in the real world. In contrast, some physicians order a battery of laboratory tests without clinical justification; and then proceed to treat the abnormal results irrespective of their relevance. There are some who practice EBM in a similar inappropriate fashion.
Quality of Evidence
Evidence used for decision-making should be critically appraised for quality. This essential step determines its internal and external validity. Quality usually refers to two different aspects, viz., methodological quality (related to the study design) and process quality (related to the procedures used to generate the evidence). The former includes methodological refinements in research studies that are designed to reduce bias, e.g., randomization and allocation concealment to minimize selection bias, intention-to-treat analysis to mitigate attrition bias, etc. The latter includes procedures to minimize errors in data collection, e.g., averaging of multiple measurements, instrument calibration, using gold standard tests or methods, etc. There are various tools available for appraising primary and secondary research for methodological quality, whereas the judgment of process quality is often left to the discretion of researchers, or journal editors or the peer review process. Quality of evidence does not imply the quality of the reporting or presentation of the evidence. The traditional belief that publications in prestigious journals, or authored by renowned investigators, can be assumed to be of high quality, is not necessarily true.
Tertiary Research
The complexity involved with understanding, interpreting, and thereafter applying research evidence has spawned a new brand of analysis referred to as tertiary research (for want of a better term). This form of research has become critical for healthcare stakeholders (professionals, patients, policy-makers, advocacy groups, lay press, etc.) to cut through the technical jargon in research, identify the relevant message, and provide a summary that can serve as a tool for evidence-based decisions. In that sense, it demands a very high level of skill and integrity from the tertiary researcher. The former, because it is more complicated than generating primary or secondary evidence and leaving the stakeholder to interpret the same. The latter because the tertiary researcher can consciously or unconsciously mislead the stakeholder in the direction of his/her own biases. Unfortunately, although a lot of tertiary research products are in circulation (commentaries, evidence-based editorials, evidence summaries, and nonsystematically generated guidelines/recommendations) which are appealing to the end-user, the methodological process for validation of such research is still under development.
CHALLENGES TO EVIDENCE-BASED CARE IN PEDIATRICS
Decision Questions versus Clinical Questions
Healthcare professionals expect research evidence to provide answers to their decision-making questions, such as “Should I use this medicine or vaccine or test or procedure?” However, research evidence is designed to address specific clinical questions in the famous PICO format [identify the patient problem or population (P), intervention (I), comparison (C), and outcome(s) (O)] from which individual stakeholders (professionals, patients, and healthcare systems at large) are expected to derive conclusions and then make their own decisions. Thus, evidence cannot dictate what a professional should do. It is designed to provide information on the basis of which, the professional and patient together have to make a shared decision, incorporating clinical experience and personal values, respectively. This requires knowledge and skills to understand, interpret, and apply research evidence. This is the art of practicing the science of EBM.21
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Practical Challenges in Accessing and Applying Evidence
Often, healthcare professionals appreciate the value of incorporating evidence in their decision-making processes, but the evidence is either unavailable or inaccessible (at the time or place required). This is largely related to the healthcare setting wherein crowded clinics or wards and limited technological facilities pose challenges to the real-time access and application of research evidence. 22This situation has undergone tremendous improvement with the availability of mobile phone-based applications and better internet connectivity at the point-of-care.
Generalizability of Evidence
Another major limiting issue in evidence-based practice is the issue of generalizability of evidence. As for many issues in healthcare, evidence generated from a particular setting may not be directly applicable to other settings. This could be on account of biological characteristics of the patient (population) or disease, healthcare system differences, locally relevant guidelines, or even cultural practices or traditions. Some of these limitations may operate even when evidence is generated from the same or similar setting. For example, evidence on milder forms of disease cannot be extrapolated to patients with severe disease, or those with comorbidities, etc. In such situations, professional judgment is required to determine applicability of evidence, i.e., can the evidence be implemented in my setting? If yes, would it result in similar effects?
Efficacy versus Effectiveness
Research evidence usually presents information on the efficacy (and sometimes) safety of interventions from research settings, whereas in real life, we require information on effectiveness. In simple terms, efficacy addresses the issue “Does this work in a highly controlled research setting?” whereas effectiveness reflects “Will this work in the real-world healthcare setting that I am working in?” Assessment of effectiveness requires a careful appraisal of issues beyond efficacy and safety, and encompasses aspects like the healthcare setting, feasibility, logistics, and cost considerations of the intervention (and its alternatives), social aspects, and other issues.
Evidence on Healthcare Interventions versus Health Problems
It should also be recognized that healthcare interventions (therapeutic/diagnostic) rather than health problems are the usual starting point for generating primary and secondary research evidence. Therefore, practice of EBM can become a process of applying interventions that are supported by evidence, at the cost of ignoring other options for which robust evidence on efficacy may not be readily available. For example, research evidence may suggest that a particular vaccine is efficacious in a given setting, but there may not be sufficient evidence on alternate measures to tackle the healthcare problem (through better sanitation, hygiene, nutrition, education, etc.). In such a situation, implementation of the efficacious intervention gives the impression of evidence-based practice.
GRADING OF EVIDENCE
Recognizing that all evidence is not of equal quality for the purpose of making decisions, the GRADE approach was initiated about two decades back. GRADE is an acronym for Grading of Recommendations Assessment, Development and Evaluation. It is a system to evaluate the strength of evidence and the level of confidence that can be placed in it. In general terms, high-quality evidence reflects a high level of confidence that the effect presented in/by the evidence is close to the true effect. Reduced levels of confidence are reflected by terms such as moderate, low, or very low quality of evidence. In addition, the GRADE approach entails a semiobjective assessment of the management alternatives, and patient values; based on which evidence can be downgraded or upgraded. This helps to frame recommendations for healthcare practice along with explicit statements on the strength of the recommendations.
EVIDENCE TO DECISIONS
The GRADE approach also facilitates stakeholders to examine the evidence for contextual relevance and local applicability. This is important for translating high-quality research evidence to real-world healthcare decision-making. The Evidence to Decision (EtD) framework clarifies criteria used to assess specific interventions and the available alternatives, the basis for decision judgments, the strength and quality of research evidence, and locally relevant considerations. EtD frameworks are thus helpful for guideline development panels to make judgments about the priority level of the healthcare problem (in terms of epidemiologic burden, urgency, etc.), the balance between the expected desirable and undesirable effects, certainty of the evidence, resource allocation issues, judgments on cost-effectiveness, potential impacts on equitable distribution, stakeholder acceptability, and implementation feasibility.
BEYOND EVIDENCE
Health Technology Assessment
It should be recognized that evidence-informed pediatric practice involves much more than accessing, appraising, and applying the relevant evidence. It involves a careful appraisal of additional issues such as financial costs, cost-effectiveness of interventions, social implications, feasibility, logistics, long-term impact, etc. These components together form the broader discipline of health technology assessment (HTA). Most developed healthcare systems rely on information provided by HTA organizations/institutions to guide their decision-making system. In contrast, many developing healthcare systems lack such facilities and experience challenges in making rational decisions at the individual, institutional, organizational, or national level.
Clinical Practice Guidelines
It may be too much to expect busy healthcare professionals to undertake the multiple steps of EBM outlined in Table 2, during each and every encounter with patients. It would be much easier if robust evidence on specific PICOT questions could be channelized into guidance for healthcare professionals to make evidence-informed clinical decisions.
Broadly, clinical practice guidelines (CPGs) are documents that guide (but not necessarily impose) decisions regarding facets of healthcare such as diagnosis, treatment, prevention, etc. These are distinct from the traditional “expert opinion” or “expert consensus” based guidance, in the sense that they are based on thorough examination of current evidence, and the guidance offered is directly linked to that evidence, with remarks on estimates of confidence in the evidence. The main product of guidelines is evidence-based recommendations that may include aspects such as risk/benefit ratio, cost-effectiveness, and implementation considerations. Many guidelines explore alternate options or courses of action, to help healthcare providers and recipients to make shared decisions, based on the evidence.
One of the benefits of developing and implementing evidence-based guidelines is that it can contribute to standardizing healthcare delivery, thereby enhancing quality. It also helps greatly in minimizing the use of healthcare interventions that are not of proven benefit. Naturally, the success of CPGs depends on compliance of healthcare providers to these guidelines. This necessitates mechanisms for audit of healthcare practices, and provisions for instituting measures to ensure compliance. There is also extensive debate about whether guidelines should be interpreted as “rules” that must be mandatorily followed, or merely as “aids” to healthcare providers.
High-quality guideline documents clearly outline the scope and purpose of the guidance, and ensure that all relevant stakeholders are involved in development. Thus, guidelines relevant to pediatric practice should ideally include not only healthcare professionals such as pediatricians, pediatric nurses, etc., but also representatives of patients and other child health advocates. The quality of guidelines naturally rests on the methodological processes used which should 23include systematic search for high-quality evidence, and a clear linkage between the evidence and the recommendations framed. Additional hallmarks of quality include clear declarations of potential conflicts of interest of the guideline development panel members, and editorial independence.
EFFORTS TO ENHANCE EVIDENCE-BASED CARE IN PEDIATRICS, IN INDIA
Recognizing the need to support pediatricians in using evidence as a tool in clinical practice, “Indian Pediatrics” initiated the EURECA section some years back. EURECA is an acronym for Evidence that is Understandable, Relevant, Extendible (to the local setting), Current and Appraised critically. The goal was to provide high-quality, up-to-date evidence on various issues in child health in an easy to understand format, thereby facilitating pediatricians in the country and region, to make informed decisions in pediatric practice.
Later, the EURECA section in Indian Pediatrics was replaced with a Journal Club, that appeared every alternate month. Each Journal Club critically assessed a current research publication from the evidence perspective, and also the clinical perspective. The goal was to empower pediatricians to appreciate the nuances of EBM, and how to bridge research evidence to clinical practice. However, the exigencies associated with the coronavirus disease 2019 (COVID-19) pandemic have temporarily halted the Journal club.
Indian Pediatrics has been conducting Research Methodology and Thesis Writing workshops for several years. These workshops expose pediatricians in training, to understand basics of research methodology, and also to design (and conduct) good quality research through their thesis studies. Further, there is emphasis on reporting and presenting the research well.
The Indian Council of Medical Research (ICMR) funded Advanced Center for Evidence-Based Child Health located at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh has been conducting multiple training workshops for those involved in child health, including pediatricians, pediatric nurses, and public health specialists. Further, the center undertakes systematic reviews on topics relevant to child health in India, and provides inputs for clinicians and policy makers.
In India, the first glimpses of HTA training emerged in 2009 through the SIGNET Program. SIGNET was an acronym for Singapore Indian Group Networking for Empowerment Training. Through this program, funded by the Temasek Foundation (Singapore), Indian healthcare professionals (physicians, nurses, and hospital administrators) in the public as well as private sectors were empowered to become users of evidence (both external as well as local) for managing locally relevant healthcare problems. This was a unique approach going well beyond training in research methodology or EBM, to transform local institutional healthcare systems.
More recently, the Government of India has established a Medical Technology Assessment Board and an HTA Unit in the Department of Health Research. Formal HTA is being conducted on relevant issues. There are also numerous training workshops and courses to develop better understanding of HTA.
THE WAY FORWARD FOR EVIDENCE-BASED CARE IN PEDIATRICS
The way forward to develop a system of evidence-based care in pediatrics revolves around empowerment. Empowerment is a broad term that encompasses multiple facets and multiple stakeholders. On the one hand, we need to empower healthcare providers and healthcare consumers to contribute together to generate high-quality evidence. This includes research evidence (through well-designed studies, systematic reviews, and even tertiary research) as well as clinical evidence (through meticulous documentation of observations, peer review, and external validation). This in turn requires developing a pool of people with the requisite knowledge and skills who in turn can become the nucleus for building up (and sustaining) the effort. Such efforts have been made in recent years through the activities of the South Asian Cochrane Network and Center, SIGNET program, the Advanced Center for Evidence-Based Child Health, Indian Academy of Pediatrics, and its official journal, Indian Pediatrics. These efforts have been highly successful in enlarging the pool of producers who generate primary and secondary evidence.
However, currently most of these efforts are provider-driven rather than demand-driven. It is believed that a demand-driven approach can be boosted through introduction of principles of EBM at the undergraduate training level (for all categories of healthcare professionals associated with child health) and most important, postgraduate training in Pediatrics. This approach would create a large pool of users of evidence, who would not only create demand for evidence-informed healthcare practices, but also create a demand among healthcare recipients/consumers for evidence-based practice. The list of evidence users extends far beyond healthcare professionals and encompasses virtually everyone who participates in decisions affecting children. This includes policymakers, organizational leaders, healthcare institutions, lay press, and of course the general public. In fact, each and every person in the country (whether professional or lay person) is a healthcare stakeholder who can be empowered.
Therefore, empowerment efforts in India should focus on both evidence users (who would demand appropriate evidence on locally relevant issues) and evidence producers who could fulfill the demand.
1.4 Ethical Issues in Pediatrics
Sanjiv Lewin
Physicians are faced with increased ethical dilemmas especially in the practice of pediatrics with advances in technology and social changes. Recognition of ethical conflicts and consults for appropriate decisions are uncommon in our practice (Lantos JD et al., 2019). It is society that permits us to practice our profession with an understanding that we will be professional and ethical in our practice as we are given the honor of serving society as physicians. Thus, abiding by our code of ethics becomes essential to maintain our place in society. Only the profession can (self) regulate ethical conduct and thus strengthen our professional place in society. This chapter gives us an overview of ethics in the practice of pediatrics with a purpose of education (Savitha D et al., 2018).
PRINCIPLES OF ETHICS
Definition
Ethics is a generic term that covers many aspects of examining and understanding the moral life. Beauchamp and Childress (Principles of Biomedical Ethics, 2009) identify principles that assist us in making moral ethical judgments in clinical practice. The core principles are beneficence, nonmaleficence, justice, and autonomy.
Beneficence
Beneficence is simply “Always Do Good.” Always do good for your patient who remains at the center of all a physician's roles and responsibilities. In pediatrics, it means that the wellness of the child we care for, remains at the center of all our clinical decisions. This principle insists that it is the physician's responsibility to always protect and promote the best interests of the child (our patient). Educating and providing symptomatic medicines for a viral fever in a child; prescribing an appropriate antibiotic for a bacterial pneumonia; advising a magnetic resonance imaging (MRI) scan for an infant with regression of milestones and a suspected degenerative brain disorder; and, advising a bone marrow aspiration for a child with suspected acute leukemia would be examples of beneficence.
Nonmaleficence
Nonmaleficence would be easy to understand as “Do No Harm.” The patient (the child under our care) remains at the center of our focus and we should always try never to advise or do anything that would harm. Should there be some harm, one needs to understand and choose an option where the benefit to the child is significantly more than the cost or harm the option will cause. Prescribing only relevant injectable vaccines to a child to prevent epidemiologically proven common or high impact childhood disease; rationalizing and hence avoiding too many chest X-rays during care of respiratory ailments in young children; and, advising a potentially painful bone marrow aspiration using adequate anesthesia when indicated are examples of decisions that attempt to minimize harm to our child. Balancing benefits versus harm (including costs to the family and may be even community) is probably the most common ethical decision we take as physicians in resource constraint settings.
Justice
Justice is being fair to the child primarily and controversially extended to include fairness to the guardians in resource constraint settings. One needs to fairly distribute benefits and also probably risks and costs. Choosing sparse resources while caring for twins in a neonatal intensive care setting; deciding admission to children attending a busy emergency facility when beds available are limited; raising funding for expensive rare interventions (Dressler and Kelly, 2018); and, probably one may argue insisting on interventions way beyond family economic capacities are examples where justice is an important principle that needs to be considered.
Autonomy
Autonomy is respecting an individual's values and beliefs. This becomes more significant as the child grows up for as long as they are dependent children, immature, and poor of understanding; most decisions are taken by parents and legal guardians. Autonomy insists that the patient (family) perspectives be taken into consideration in redefining the partnership in healthcare that exists between doctor and patient. Legally the age of 18 years is when the individual has legal rights to decide for themselves. However, it is not uncommon to have an adolescent with the maturity and understanding of what they need or not. An adolescent refusing an abortion, a child refusing an injection versus an oral option, and a family refusing treatment for a child because of their own religious beliefs or superstitions may be examples of issues related to autonomy.
ETHICAL WORKUP OF A PATIENT
When patients come to physicians, we clinically diagnose after a workup that includes a detailed history and physical examination. We may then order investigations to confirm the same and initiate specific treatment chosen from options available. This process requires a degree of clinical reasoning where data collected is analyzed and a diagnosis is justified based on evidence.
Similarly, when we feel uncomfortable with a scenario or decision, a similar ethical workup to collect facts, analyze, and justify, hence reaching a “diagnosis” and hence choosing the most ethical solution (Percival T, Medical Ethics, 1803). Steps of an ethical workup may be summarized as below:
- Medical facts: Collecting clinical facts of the patient including options available
- Ethical obligations: Identifying obligations of the physician to the patient, family, profession, institution, and society
- Conflicts: Identify conflicting obligations if any
- Consensus: Reaching a decision that minimizes conflict
Ethical Obligations
The physician clearly has an obligation not only to the child but also to society clearly in the case of vaccine preventable diseases.
Conflicts
Beneficence and nonmaleficence are clearly in favor of the physician's decision to vaccinate the child for the risk:benefit ratio is high. The issue of justice arises as not vaccinating the individual increases the risk of transmission in the population. One may argue that there is a conflict with the principle of autonomy of the guardian and minor. 25The child is immature and does not understand the situation, but one may argue that (social) justice needs to prevail if it is the parents who refuse to vaccinate their child.
Consensus
An immature child who cannot understand the situation, needs, and benefits may not be able to claim the need for physicians and parents to respect their autonomy in this case at this age. The benefit is overwhelming and harm is minimal for vaccination. Justice is served as not only does it protect the individual child, but also improves population protection through reduction of transmission of vaccine preventable diseases. It may be argued that insisting on the vaccination irrespective of a crying upset 18-month-old child would be considered ethically correct. Educating the guardians will be necessary to implement this decision. Of course, an adolescent even though <18 years old refusing a vaccination may raise different challenges requiring different decisions to make it ethical.
Ethical Obligations
As a pediatrician, the primary concern is the wellbeing of the child. However, the patient being a minor your relationship arguably may also extend to the legal guardians (i.e., parents) though it does not bind the decision. Your professional obligations remain with what is best for your child patient. Your institution may differ being a government or private institution; the former with the mandate to provide public sponsored care and the latter based on the ability to pay for costs incurred. Society clearly dictates that you behave professionally in the interest of every individual even the child.
Conflicts
This certainly exists as the parents clearly do not want any intervention for their child and are not only in conflict with the physician, but also at conflict with the child's needs.
Consensus
Discussions toward a consensus may need to include not only the parents, but also social workers and counselors where discussion occurs on many fronts. What is in the best interest of the child? Are the parent's choices aligned with that of the child or should we play child's advocate? Does not the physician have a responsibility to parents and society? What will be the outcome should we agree or disagree with the parents? In an ideal world, the consensus would clearly be to keep the child's wellbeing optimum and operate through a court order even if it means placing the child in the state social welfare system. In our settings, this is certainly much more of a challenge given time factors and an overwhelmed judicial and social welfare system.
INFORMED CONSENT AND ASSENT
A child needs a bone marrow transplant. Should we obtain consent from the child and/or parents?
A corner stone of biomedical ethics is the concept of informed consent. Consent is most essential for strengthening trust in any doctor–patient relationship. Informed consent is even more vital in research ethics. Common law dictates that “every human being of adult years and sound mind has a right to determine what should be done with his or her body.” Hence, all medical interventions interfering with the human body (including the mind!) require consent.
Consent
The Indian Contract Act (1872) defines consent as “when any two persons agree upon the same thing in the same sense they are said to consent.” Consent may be verbal or written.
The Indian Penal Code (1872, 1860) goes on to recognize that for clinical examination, diagnosis, and treatment consent can be given by any person who is conscious, mentally sound, and over the age of 18 years. Consent may be implied or express.
- Implied consent or “tacit consent” for history taking and simple physical examination when one requests a consult.
- Express consent may be oral or written usually required for procedures and interventions when offered an intervention.
Consent should always be informed. Information must be comprehensible in the vernacular language and in nonmedical terms though there is place for a therapeutic privilege where duty to disclose is subject to exceptions. Exceptions may be if the patient refuses to be informed, or if information is unlikely to be processed rationally leading to significant psychological harm or frightening patients.
Assent
For all children, proxy consent “substitute consent” is the norm with parents or legal guardians giving consent for children under their care. Between the ages of 12 and 18 years, assent is a concept that respects autonomy of a mature minor. Assent is an agreement when legally the person cannot give consent. It indicates that the child is old enough to understand and willing to participate in what is being proposed, either in clinical care and treatment or in research studies. Hence, legally consent is required from parents and legal guardians of children under 18 years, but it is vital to obtain assent (agreement) from the child itself. We may explain the need for a surgical procedure for a child with appendicitis and obtain a written informed consent from the parents. Simultaneously, the physician may sit down next to the child and in developmentally appropriate language explain what the child should expect and obtain a willingness to participate. This second step is an example for assent.
DISCLOSURE COUNSELING
A child has been diagnosed with human immunodeficiency virus (HIV) infection. Should we tell the child?
Disclose is to make new information known to another or simply to reveal information. At times, it may be necessary “to reveal” a diagnosis or management plan to a child to strengthen trust and build on a relationship toward enhanced cooperation, hence improving adherence. This is especially important when children begin to grow up and ask questions demanding answers. Children may ask many questions like for those infected with HIV: How long will I need to take this medication? Will I die from this disease? When will I die? How did I get this disease? What did I do wrong to get this disease? Successful disclosure requires physicians to understand the ability of the child to understand and comprehend (intellectual development and maturity of coping skills) as well as clarity in existing family support mechanisms and parental understanding of the situation. There is no ideal age for disclosure, usually appropriate when questions are raised by the child. It remains a process never a one-time conversation with simple to more complex information being provided in bits.
Many parents and guardians of children fear disclosure especially related to serious illnesses (cancer, tuberculosis, leprosy, HIV, etc.) as they worry about the fears, emotional wellbeing, and ability to cope of their children. Stigma and fear of discrimination also are high on the list given the possibility that children may share information with those not concerned with the family.26
Disclosure is an important step forward to improve successful adherence and enhance the partnership. Self-esteem improves while depression in both child and parents diminishes with disclosure. It is often that children learn of their illnesses with inadequate information and wait for their own parents, guardians, and physicians to be honest with them. Disclosure strengthens the doctor–patient relationships. An adolescent child on daily antiretroviral therapy requires disclosure counseling to strengthen partnership and adherence by addressing guilt, anger, and understanding of needs; and a child with retinitis pigmentosa progressively going blind will also need disclosure consoling to enable preparation and coping mechanisms are examples for disclosure.
WITHHOLDING AND WITHDRAWING TREATMENT
A child has been on ventilator for over 2 weeks and appears seriously brain damaged. Should we withdraw or withhold treatment?
Physicians are expected to value life and do everything in their power to save life. At times, one wonders if we are prolonging life or prolonged death. Death may be cardiac or brain (whole or higher function) death. Complexities of technology in healthcare delivery now days are intense and only increasing. Traditionally, interventions are considered ordinary or extraordinary suggesting that they were either common and simple; or, uncommon and complex interventions. These terms are not easy to use to classify interventions. Hence, preferred terms used are appropriate, or inappropriate interventions. An example is a when a severely asphyxiated newborn is on a ventilator and dialysis for multiple organ dysfunction with a poor prognosis. If the parents decide to withdraw care, it may mean discontinuing ventilation, dialysis or even the nasogastric feeds.
At present, there are no laws that govern withdrawing or withholding interventions though it is not uncommon for concerned physicians to sit down and discuss prognosis and costs to families while looking at various options including withdrawing or withholding. Recognizing the possible futility of medical interventions is an ethical issue that requires us to accept that dying is not necessary losing, but a part of the cycle of life and we are not God(s).
ACCEPTANCE OF GIFTS
Should we accept gifts from pharmaceutical representatives?
Physicians have a fiduciary responsibility to all our patients. The pharmaceutical industry is a business with a purpose to earn profits for their shareholders. The industry has enormous budgets allocated to maintaining an army of representatives to visit, “educate,” and “update” physicians as well as to fund gifts for physicians. It is psychologically proven that persistent visits by pharmaceutical representatives on many occasions through the week for prolonged times are effective to change prescription behavior. The visit usually includes exchanging pleasantries, praising the physician, speaking of the products, and ends with a gift (samples, pens, pads, books, invitations, etc.). Of course, those who are heavy prescribers of their products get additional awards of various degrees from invitations to talk at conferences and at continuing medical educations (CMEs) at expensive hotels or resorts, with all necessary frills. An added opportunity to partake of a meal is a strong incentive for behavior change. So, what is wrong if anything? We may argue and say that we have updated knowledge following attending such educative talks. It is often that samples are handed out to try out on our patients to see if they are effective or not. The visits are also argued as reciprocal courtesy we show each other being a part of the healthcare industry. The most common denial all of us good doctors give is that there is absolutely no way our prescription behavior patterns will change simply by a representative's visit or accepting pen and pad! Unfortunately, we are very wrong.
There is much literature that has repeatedly studied and demonstrated the effect of gift giving on physician's prescription habits that change with time. Factors enhancing this effect include the number of visits made, the acceptance of gifts by the physicians, and food is especially a good factor! As professionals, a status earned and permitted by society, we are certainly duty bound to keep ourselves up-to-date and competent as well as follow an ethical code of conduct that is self-regulated by our peers. Our focus of clinical care and treatment is always on our patient's best interest. If there is any conflict of interest in our decision-making process where we choose one over another for reasons not keeping our patients’ best interest in mind, then we are failing in our duty as professionals. Accepting gifts from pharmaceutical industry changes prescription behavior as we reciprocate the act of giving. Educational programs sponsored by industry also pressurize organizers not only to call industry friendly speakers, even sometimes provides slides and material to talk on and dictate topics to be covered. As responsible physicians, it is our responsibility and duty to not accept gifts and be aware of conflicts of interest when reading, listening, or viewing education programs and material.
GENETICS AND ETHICS
Can we choose our dream baby?
The advances in genetics appear to be a double-edged sword from an ethical viewpoint. The ethical question is if we are beginning to play God? Is not tampering with genetic material and the process of fertilization and birth not directly interfering with the creation of life with all its uncertainties? On the other hand, why not use science to improve our lives and the lives of others to come, and, solve our own problems? Do we not have so many terrible genetic disorders that bring misery to individuals and their families that may be turned around by genetics? Are we on a slippery slope where if we allow one activity as being ethical then how can we not allow others who ask? Is it a perfect race that we strive for in the future? Is there going to be less perfect creatures (like us) allowed into this world or less females due to sex selection as is not uncommon in our part of the world? Related to genetics and reproductive manipulation, additional ethical issues that are raised include questions as to when does life begin and would discarding early fertilized cells amount to “killing”?
In every walk of pediatric practice, one will face ethical challenges especially where technology is available and when interpersonal relationships exist. Recognizing and responding to ethical challenges is the first step as a pediatrician.
1.5 Sustainable Development Goals for Child Health
Raju C Shah, Pratima Shah
In 2015 reviewing the results of the Millennium Developmental Goals, it was realized that some of the countries of the world need to work on certain goals to achieve poverty reduction. In September 2015, world's Heads of State and Government agreed to set the world on a path toward sustainable development through the adoption of the “2030 Agenda for Sustainable Development.” This agenda includes 17 Sustainable Development Goals, or SDGs, which set out quantitative objectives across the social, economic, and environmental dimensions of sustainable development—all to be achieved by 2030. The goals provide a framework for shared action “for people, planet, and prosperity,” to be implemented by “all countries and all stakeholders, acting in collaborative partnership.”
India along with many countries of the world realizing the opportunity to improve wellbeing of people of our country as well as planet at large embraced the program. As is evident SDGs encompass all the sectors which are important which includes Health, Education, Infrastructure, Employment, Energy, and Environment. India set time-bound targets to achieve all these goal in the time frame.
As articulated in the 2030 agenda, “never before have world leaders pledged common action and endeavor across such a broad and universal policy agenda.” Almost 169 targets accompany the 17 goals and set out quantitative and qualitative objectives for the next 15 years (Fig. 1). These targets are “global in nature and universally applicable, taking into account different national realities, capacities, and levels of development and respecting national policies and priorities.”
The 17 goals are as follows:
- Goal 1: End poverty in all its forms every where
- Goal 2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
- Goal 3: Ensure healthy lives and promote wellbeing for all at all ages
- Goal 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
- Goal 5: Achieve gender equality and empower all women and girls
- Goal 6: Ensure availability and sustainable management of water and sanitation for all
- Goal 7: Ensure access to affordable, reliable, sustainable, and modern energy for all
- Goal 8: Promote sustained, inclusive, and sustainable economic growth, full and productive employment and decent work for all
- Goal 9: Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation
- Goal 10: Reduce inequality within and among countries
- Goal 11: Make cities and human settlements inclusive, safe, resilient, and sustainable
- Goal 12: Ensure sustainable consumption and production patterns
- Goal 13: Take urgent action to combat climate change and its impacts
- Goal 14: Conserve and sustainably use the oceans, seas, and marine resources for sustainable development
- Goal 15: Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, halt and reverse land degradation, and halt biodiversity loss
- Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels
- Goal 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development
In India, National Institution for Transforming India (NITI) Aayog has been given the role to coordinate “Transforming Our World: the 2030 Agenda for Sustainable Development.” To achieve these tasks, the draft mapping of the goals and targets as an initial step on proposed nodal and other ministries has been carried out in consultation with the Ministry of Statistics and Program Implementation (MoSPI). NITI Aayog being a nodal functionary realized the need of purposeful partnership of stakeholders to pursue certain specific objectives to realize SDGs.28
To track the progress and the tempo with which we are achieving need to be continuously measured with evidence backed manner and if needed modulated so as to achieve SDGs. A most elaborate SDG monitoring system known as a National Indicator Framework which includes about 300 indicators and has a coordinated system of generating and managing data developed in our country has helped us in the success of the program. Due to this The SDG India index and Dashboard published every year has become very important tool for key monitoring and reporting.
The years 2020-21 were full of challenges due to unprecedented and dreadful pandemic due to coronavirus disease 2019 (COVID-19). However, systematic management plan focusing on specific groups and specific system-wide measures helped the world in successfully meeting the challenge.
In the year 2010, Human Poverty Index was replaced by The Global Multidimensional Poverty Index (GLOBAL MPI), which was developed by Oxford Poverty and Human Development Initiative which uses information from 10 indicators. India has ranked 62nd in this global MPI for the year 2020 out of 107 countries under assessment.
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SUSTAINABLE DEVELOPMENT GOAL FOR HEALTH
Ensure Healthy Lives and Promote Wellbeing for All at All Ages
The SDG health goal has nine targets and four subpoints (Table 1). The first three targets are continuation of MDGs, the next three are on noncommunicable diseases (NCDs), and the last three are mixed. Nine health targets and four subpoints are as described here.
Addressing Issues of Child Mortality
The Government of India adopted the National Policy for Children on April 26, 2013. Guidelines outlined in the policy must be honored by the Government at the national, state, and local levels. The policy mentions the undeniable rights of every child such as survival, health, nutrition, education, development, protection, and participation.
The policy states that the state shall take necessary measures to:
- Address key causes and determinants of child morality through interventions based on continuum of care, with emphasis on nutrition, safe drinking water, sanitation, and health education.
- Provide universal and affordable access to services for prevention, treatment, care, and management of neonatal and childhood illnesses and protect children from all waterborne, vector borne, communicable, and other childhood diseases.
The health of the mother has an important impact on the health of the child. Thus measures for improvement of mother's health are important for improving the survival of the newborn. Higher resources are allocated under National Rural Health Mission (NRHM) to states and districts with weak health indicators. The major programs addressing the needs of mother and children (at child care and child survival) are discussed below, in brief.
Institutional Delivery through Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram
To ensure skilled birth attendance by promoting institutional delivery will help to reduce both maternal and neonatal morality. Janani Suraksha Yojana provides cash assistance and encourages pregnant women to opt for institutional delivery. In Janani Shishu Suraksha Karyakram, the pregnant woman gets complete zero expense delivery including cesarean section operation, as well as transport, food, drugs, and diagnostics.
Facility-based Newborn Care
Special newborn care units (SNCUs) are setup at district hospitals and medical colleges. These care for the sick newborn and are equipped with radiant warmer, phototherapy unit, oxygen hoods, infusion pumps, laryngoscope and endotracheal tubes, bag and mask, nasal cannulas, and weighing scale. SNCU is a 12–20-bedded unit and requires four trained doctors and 10–12 nurses for round the clock services. Almost 400 SNCUs are now functional in the country.
Newborn stabilization units are setup at community health center/first referral units. These units provide services like resuscitation, provision of warmth, early initiation of breastfeeding, prevention of infection and cord care, and supporting care including oxygen, intravenous (IV) fluids, and provision for monitoring of vital signs including blood pressure and referral services. These are four-bedded units with trained doctors and nurses for stabilization of sick newborns.
Newborn baby care corners are setup in all facilities where deliveries are taking place. This is one-bedded facility attached to the labor room and operation theater for provision of essential newborn care. The services include resuscitation, provision of warmth, and prevention of infection and cord care, and early initiation of breastfeeding. The equipment at newborn care corners include weighing scale, radiant warmer, suction machine, and mucus sucker.
Home-based Newborn Care
Home-based newborn care through Accredited Social Health Activist (ASHA) workers has been initiated to improve newborn care practices at the community level and for early detection and referral of sick newborn babies. All newborns will be visited by ASHA workers as per the specified schedule, up to 42 days of life. They have to ensure recording of weight of the newborn; BCG (Bacillus Calmette–Guérin) vaccination, first dose of oral polio vaccine and diphtheria, pertussis, and tetanus vaccination; both the mother and the newborn are safe till 42 days of the delivery; and that registration of birth has been done.
Capacity Building of Healthcare Providers
Trainings are conducted under NRHM to train doctors, nurses, and auxiliary nurse midwife (ANM) for early diagnosis and case management of common ailments of children, as per the Integrated Management of Neonatal and Child Illness (IMNCI) strategy and “Navjaat Shishu Suraksha Karyakram.”
Integrated Management of Neonatal and Child Illness includes interventions to prevent and manage the most common major childhood illnesses, which cause death, i.e., neonatal illnesses, acute respiratory infections, diarrhea, measles, malaria, and malnutrition. The objective is to implement IMNCI package at the household level and subcenter, primary health center level, to provide a comprehensive newborn and child health services to address major neonatal and childhood illnesses. More than 500 districts and 500,000 healthcare providers have been trained in IMNCI.
Navjaat Shishu Suraksha Karyakram program is launched to address basic newborn care and resuscitation, and issues at birth, i.e., prevention of hypothermia, prevention of infection, and early initiation of breastfeeding. The objective of this program is to have one person trained in basic newborn care and resuscitation available at every delivery.
Management of Malnutrition and Other Morbidities
Malnutrition reduces immunity of children to infections thus increasing mortality and morbidity among children. Exclusive breastfeeding is promoted for first 6 months of life as it reduces neonatal mortality. Appropriate infant and young child feeding practices are also promoted. For prevention of anemia, iron and folic acid are provided to the children. Almost 600 nutritional rehabilitation centers have been established for management of severe acute malnutrition, across the country. Reduction in morbidity and mortality due to acute respiratory infections and diarrheal diseases is encouraged by early identification of cases and managing them properly. Promotion of zinc and oral rehydration salts supplies is ensured. Micronutrient malnutrition is addressed by supplementation with micronutrients through supplies of vitamin A, iron, and folic acid tablets.
Universal Immunization Program
Immunization program of India is one of the largest immunization programs in the world. Under this program, Government of India is providing vaccination to prevent seven vaccine-preventable diseases, i.e., diphtheria, pertussis, tetanus, polio, measles, BCG, and hepatitis B. Haemophilus influenzae B vaccine as part of a liquid pentavalent vaccine is also introduced in all the states. “Mission Indradhanush” was introduced to strengthen routine immunization which includes some newer initiatives, e.g., provision of autodisable syringe to ensure injection safety and vaccine reminder.
Mother and Child Tracking System
A web-based mother and child tracking system has been introduced to enable tracking of all pregnant women and newborns, so as to monitor and ensure that complete services are provided to them. States are encouraged to send beneficiary wise SMS alerts to ANMs on weekly basis and also reminders to beneficiaries reminding them of the dates on which services are due.
Integrated Child Development Services Scheme
Integrated Child Development Services is a centrally sponsored scheme aimed at holistic development of children below 6 years of age and pregnant women and lactating mothers by providing a package of six services comprising of (1) supplementary nutrition; (2) preschool nonformal education; (3) nutrition and health education; (4) immunization; (5) health check-up; and (6) referral services through Anganwadi center at grassroots level.
India Newborn Action Plan
The India Newborn Action Plan (INAP) is India's committed response to the Global Every Newborn Action Plan (ENAP), launched in June 2014 at the 67th World Health Assembly, to advance the Global Strategy for Women's and Children's Health.30
The ENAP sets forth a vision of a world that has eliminated preventable newborn deaths and stillbirths. It includes six pillars of intervention packages across various stages with specific actions to impact stillbirths and newborn health. The six pillars are: (1) preconception and antenatal care; (2) care during labor and childbirth; (3) immediate newborn care; (4) care of healthy newborn; (5) care of small and sick newborn; and (6) care beyond newborn survival.31
SDG India index 2020-21 report has incorporated 16 out of 17 goals and covers 70 SDG targets. It has provided goal wise results and compared with results of 2019-20 (Fig. 2). State-wise comparison is also provided (Fig. 3).
SDG India Index—Goal 3: Good Health and Wellbeing
To measure this goal and to capture 8 out of 13 SDG targets, 10 indicators are identified and monitored. Scores for this goal range for different states between 59 and 86 while for union territories (UTs) between 68 and 90. Gujarat and Delhi turned out to be best performers amongst states (Fig. 4).
Under Goal 3 related to health, there is a consistent considerable progress. One of the important targets was to reduce under 5 mortality to 25 per 1,000 live births; and as per SRS 2016-18, we have reached to 36 per 1,000 live births. Five states namely Kerala, Tamil Nadu, Maharashtra, Punjab, and Himachal Pradesh have achieved this target, 91% of children in age group of 9–11 months were fully immunized. As per same information system 94.4% of total deliveries were institutional deliveries during April to December 2019. The Maternal Mortality rate also reduced to 113 per 100,000 live births as against global target of 70 per 100,000 live births by 2030.
