PEDIATRICS: CURRENT CONCEPTS IN A NUTSHELL
Today, pediatrics is defined as the healthcare of the child from the very conception through infancy, childhood, and adolescence. In other words, pediatrics is the medical science (the science of right living), which enables an anticipated newborn to grow into a healthy adult, useful to the society.
The term, pediatrics, is derived from the Greek words pedia (meaning a child or pertaining to a child), iatrike (meaning treatment) and ics (meaning a branch of science). The contemporary understanding of this Greek term is: science of child care, preventive as well as curative. The term, pediatrician, is employed for a physician that specializes in the overall healthcare of the neonates, infants, children, and adolescents.
Pediatrics, therefore, is concerned with the health of infants, children, and adolescents, their growth and development, and attaining full potential as adults. Broadly speaking, the pediatrician's responsibility is to care for the physical, mental, and emotional health from conception to maturity. Additionally, he is also expected to demonstrate concern for the social, environmental, and cultural influences that are known to have considerable fallout on children and their families.
Amongst the factors that have a bearing on health problems of children rank climate, environment and geography, prevalence and ecology of infectious agents and their hosts, agricultural resources and practices, education, economic, social and cultural considerations, stage of urbanization and industrialization, and gene frequencies.
In United States of America (USA), pediatrics includes individuals up to the age of 21 years. United Nations International Children's Emergency Fund (UNICEF) is content with up to 18 years as the pediatric age group. According to the Indian Academy of Pediatrics (IAP), health problems of children up to 18 years (inclusive) should be the responsibility of the pediatricians.
PEDIATRICS AS AN INDEPENDENT AND UNIQUE SPECIALTY
There are quite a few logics regarding pediatrics as an independent medical specialty.
- First, the health problems of children differ from those of adults in many ways.
- Second, children's response to an illness is influenced by age.
- Third, management of childhood illness is significantly at variance with that of an adult.
- Finally, children also need special care since they are world's most important resource and amongst the most vulnerable in the society.
This modern concept of pediatrics lends it a unique status. Unlike other specialties, it deals with the excitingly dynamic process of continuous care of the growing child, nay the whole child. The semantic, whole child, according to UNICEF, means that assistance for meeting the needs of children should no longer be restricted only to nutrition which is of immediate benefit to them. Instead, it should be broad-based and geared to their long-term personal development and to the development of the countries in which they live. This approach is called country health programming. The differences between a child and an adult are appropriately spelt in the saying, the child is not a little man or the child is not a miniature adult. One cannot apply the principles of adult medicine directly to child population that has a unique biology with:
- Distinct nutrition needs for ensuring growth and development
- Different clinical presentation of disease
- Distinct risk factors of disease
- Several disease entities that are exclusive to children
- Different drug dosage.
CHANGING PEDIATRIC SCENARIO
Pediatrics as a discipline per se took birth in 19th century in the prosperous countries of the West. Notwithstanding the fact that health care of children occupied pride of place in the ancient Indian health system (also in Chinese and Greek systems), and formal recognition of pediatrics as a discipline is a recent development in India and other resource-limited countries. Paradoxically, over one-half of the world's total children (1.5 billion out of 3 billion) live in these regions. In India, for instance, around 40% of the 1.3 billion population is constituted by the most vulnerable segment, i.e. infants and children. Further, a high proportion of the total morbidity and mortality is accounted by the pediatric age group. The corresponding figures for the prosperous countries are considerably low.4
Apparently, appreciation of the significance of child care has come rather late. Let us hope it is not too late! In India, for example, our achievements in child health and care are a cocktail of success, lukewarm success, and failure.
On the positive front, we can take pride in:
- Total eradication of smallpox
- Total eradication of Guinea-worm
- Attainment in institutional delivery rate of 80%
- Success of oral rehydration therapy
- Maternal and neonatal tetanus-free status
- Polio free status
- Fall in incidence of serious forms of tuberculosis
- Fall in mortality from tuberculosis
- Fall in prevalence of severe malnutrition
- Fall in mortality from diarrheal disease
- Five-fold hike in school enrollment of girls since independence
- Fall in infant, perinatal, neonatal, and under-5 mortality rates (U-5MRs).
On the negative (somewhat failure) front, we have:
- Persistence of still high incidence of tuberculosis and emergence of resistant strains
- Still high child mortality indices (Table 1.1)
- Inadequate availability of safe drinking water
- Insufficient sewage disposal
- Still unacceptably high dropout rate in schools (especially in case of girls).
In other words, pediatrics which was by and large a scratch in India (just a poor appendage of general/internal medicine), when it became independent in 1947, has come a long way (Box 1.1). Yet, the progress has fallen short of what should have been attained.
A large chunk of pediatricians (90%) in the Indian subcontinent (perhaps in most developing countries) is generalist though many of them have an area or two of special interest. Thus, by and large, each and every pediatrician is seemingly doing everything.
Though some centers have started the pediatric subspecialties, their growth remains quite slow, except for neonatology. More recently, voice has been raised to develop pediatric subspecialty divisions in all medical colleges. It has been argued that denial of a super/subspecialty care to children has no justification whatsoever.
At the same time, it is felt that a spirit of partnership and shared responsibility should be developed between the limited number of pediatric subspecialists and the general pediatricians and the physicians who still continue to offer pediatric care as well. In this context, the initiative of the Indian Academy of Pediatrics (IAP) to ask the IAP subspecialty chapters to prepare guidelines for management of common pediatric problems, which can be put on Internet and linked to the IAP website, is indeed commendable. There is a need for affiliation of the IAP subspecialty chapters with the subspecialty international associations. Hopefully, this approach would contribute to the development of the subspecialties at an international level.
Adolescent medicine, though fairly well-established in the West, is yet at a conceptual stage in India and neighboring countries. The IAP has advocated that pediatric care be extended up to (and including) 18 years of age. As a matter of fact, a commendable beginning was made in India with the declaration of the year 2000 as the IAP Year for the Adolescence and Child at Risk. Subsequently, every year we continue to observe IAP Child and Adolescent Health Care Week in the month of November, ensuring that 14th November essentially falls within the week.
More recently, IAP has launched a fresh initiative, Mission Kishore Uday, which aims at addressing the health needs of the adolescents in India (Box 1.2). Hopefully, the mission shall contribute to better health and wellness for our teenagers (Fig. 1.1).
Fig. 1.1: Adolescent health. This no-man's land, neglected by physicians as well as pediatricians, is now beginning to receive increasing attention from pediatricians. IAP's Mission Kishore Uday is a worthy step in this behalf.
Apart from the practicing pediatricians, the collaboration from the international agencies like World Health Organization (WHO) and UNICEF and Non-Governmental Organizations (NGOs) like Child Rights and You (CRY), in addition to the Union and State Governments is a must for success of the strategy. Also, see Chapter 7 (Adolescent Medicine).
CHILD HEALTH IN INDIA'S NATIONAL HEALTH SYSTEM
National programs on child health, in operation since long, include Universal Immunization Program (UIP), Diarrheal Disease Control Program, Acute Respiratory Infections Control Program, Child Survival and Safe Motherhood Program (CSSM), Reproductive and Child Health (RCH) Program, etc. In order to meet with the child health challenges yet more energetically, the relatively new programs have been incorporated, including:
- National Health Mission
- India Newborn Action Plan (INAP)
- Mission Indradhanush
- Home-based Care of Young Child
- Swachh Bharat Mission
- Ayushman Bharat.
National Health Mission
This, India's umbrella program, was launched in 2005 (Fig. 1.2). Under this program, many schemes, initiatives, and programs have been brought to provide universal access to quality health care. Its major subunits are: National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM).
National Rural Health Mission
India's flagship health initiative, the NRHM is an initiative undertaken by the Government of India (GOI) to address the health needs of underserved rural areas. Its major goal is providing accessible, affordable, accountable, effective, and reliable primary health care, and bridging the gap in rural health care through creation of cadre of Accredited Social Health Activists (ASHAs). This mission integrates multiple vertical programs.
Fig. 1.2: National Health Mission—currently, this is India's flagship program having under its umbrella several health-centric schemes, initiatives, and programs.
It was launched in 2005; NRHM was initially tasked with addressing the health needs of 18 states that had been identified as having weak public health indicators. Under the NRHM, the empowered action group (EAG) states as well as North Eastern States, Jammu and Kashmir, and Himachal Pradesh have been given special thrust.
The spotlight is on establishing a fully functional, community owned, decentralized health delivery system with intersectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, and social and gender equality. Institutional integration within the fragmented health sector was expected to provide a focus on outcomes, measured against Indian public health standards for all health facilities.
The focus on covering rural areas and rural population will continue along with upscaling of NRHM to include noncommunicable diseases and expanding health coverage to urban areas.
Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH + A) Strategy
Realizing need for extra thrust on neonatal and adolescent health, a new program, Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH + A) strategy was launched in 2013 under the NRHM.
The RMNCH + A strategy is based on provision of comprehensive care through five pillars, or thematic areas of reproductive, maternal, neonatal, child, and adolescent health, and is guided by central tenets of equity, universal care, entitlement, and accountability. The plus within the strategy focuses on:
- Including adolescence for the first time as a distinct life stage
- Linking maternal and child health to reproductive health, family planning, adolescent health, human immunodeficiency virus (HIV), gender, and preconception and prenatal diagnostic techniques
- Linking home and community-based services to facility-based care
- Ensuring linkages, referrals, and counter referrals between and among health facilities.
Rural health with emphasis on child health, in particular occupies a central place in India's health policy as depicted in pyramid with subcenters at the bottom through community health centers in the middle and medical college(s)/tertiary hospitals on top (Fig. 1.3).
National Urban Health Mission
National Urban Health Mission aims at improving the health status of the urban poor, especially slum dwellers, thrust on public health—sanitation, clean drinking water, vector control, etc. and strengthening public health capacity of urban local bodies. The proposals under this subdivision of NHM include:
Fig. 1.3: A pyramid representation of National Rural Health Mission (NRHM) structure. Note that at the base are subcenters which are fed by the frontline workers, i.e. Accredited Social Health Activist (ASHA) and Anganwadi Workers (AWW). On top is the block-level hospital.
- One Urban Primary Health Center (U-PHC) for every 50–60 thousand population.
- One Urban Community Health Center (U-CHC) for 5–6 U-PHCs in big cities.
- One Auxiliary Nursing Midwives (ANM) for 10,000 population.
- One Accredited Social Health Activist (ASHA) for 200–500 household.
India Newborn Action Plan
India newborn action plan, in operation since 2014, outlines a targeted strategy for accelerating the reduction preventable newborn deaths and stillbirths. It defines the latest evidence on effective interventions which are likely to contribute to reduction in the burden of stillbirths, perinatal and neonatal mortality and maternal deaths. The goal is to achieve a single digit stillbirth and neonatal mortality rate (NMR) by the year 2030.
Mission Indradhansha
A pan-India immunization drive, launched in 2014, aims at a minimal 90% coverage of vaccination against the infectious seven diseases, i.e. tuberculosis (BCG), polio, diphtheria, pertussis, tetanus, measles, and hepatitis B by the year 2020.
Home-based Care of Young Child
Home-based care of young child (HBYC) launched in 2018, aims at ensuring introduction of complementary feeds at 6 months of age along with continuation of breastfeeding, counseling for immunization, growth monitoring, etc.
Intensified Diarrheal Control Program
In order to further cut down morbidity and mortality from diarrheal disease, since 2014 Intensified Diarrheal Disease Fortnight is being observed. The stress is on use of ORS and zinc.
Ayushman Bharat Yojana
Launched in 2018, this scheme aims at making interventions in primary, secondary, and tertiary care systems, covering both preventive and promotive health, to address health care holistically. Its two wings are Health and Wellness Centers and National Health Protection Scheme (NHPS). The health and wellness centers provide the following major services:
- Pregnancy care and maternal health services
- Neonatal and infant health services
- Child health
- Chronic communicable diseases
- Noncommunicable diseases
- Management of mental illness
- Dental care
- Geriatric care emergency medicine.
INDIA'S NATIONAL HEALTH POLICY 2017
India's National Health Policy 2017, the third since independence (first 1983 and second 2002), promises a hike of 2.5% (from the earlier 1.5%) of GDP on health care. The policy aims at shifting focus from “sick-care” to “wellness”, by promoting prevention and well-being of the citizens. The provision, aimed at impacting the child health and survival, includes
- Reduction in under-5 mortality to 23 by 2025 and maternal mortality from current 167 to 100 by 2020.
- Reduction of 40% in prevalence of stunting of under-5 children by 2025.
- Reduction of infant mortality rate (IMR) to 28 by 2019.
- Reduction of neonatal mortality to 16 and birth rate to “single digit” by 2025.
TROPICAL PEDIATRICS: RADICAL CONCEPT
Conventionally speaking, the term, tropical pediatrics, denotes care of children in the tropical countries, i.e. countries occupying the region between tropic of Cancer and tropic of Capricorn. With the exception of Australia and Singapore, all these countries are disadvantaged on account of economical deprivation. In majority of these countries, the per capita income is under US $775. High infant mortality and under-5 mortality rates are common denominators; so are the parasitic diseases. Despite tropical environmental factors, Malaysia and Sri Lanka are successfully catching up with an IMR of 10 and U-5MR of 11/1,000 livebirths.7
The so-called tropical diseases are no longer restricted to the tropics only. Factors such as globalization and shrinkage of the world with a free exchange of vectors and microorganisms have spread them to the nontropical countries such as those of Europe and America with special involvement of the underprivileged. Afghanistan is a glaring example of a country outside the tropics hit by the tropical diseases as a result of over three decades of civil war. Its IMR is as high as 70/1,000 livebirths.
Thus, more crucial than the tropical environment in development of tropical diseases is the economy and living standard of the community. For this reason, we need to redefine the term, tropical pediatrics, as care of children of the economically disadvantaged communities, not only in the tropical countries, but also in the nontropical countries.
RIGHTS OF THE CHILD: YESTERDAY, TODAY, AND TOMORROW
Child Rights Under United Nations
- The United Nations’ Declaration of the Rights of the Child as far back as in 1959 (Box 1.3), to which India is a signatory, gives the child pride of place, as also makes the people aware of his needs and rights and their duties toward him.
- Defense for Children International, Geneva, has been in operation since 1979 to ensure ongoing, systemic international action, especially directed toward promoting and protecting the rights of the child. November 14 is observed as Universal Children's Day ever since 1954. The United Nations has assigned the responsibility to promote this annual day to the UNICEF.
Since 1989 the realization that children have special needs and hence the special rights have given birth to an international law in the shape of Convention on the Rights of the Child (CRC). The provision of the Convention was confirmed in 1990 by the World Summit for Children. Now, the Convention is credited as the most widely ratified human rights treaty in the world.
Empowered with 54 Articles, the Convention defines children as people below the age of 18 years (Article 1) whose best interests must be taken into account in all situations (Article 3). It protects children's right to survive and develop (Article 6) to their full potential, and among its provisions are those affirming children's right to the highest attainable standard of health care (Article 24) as shown in Figure 1.4 and to express views (Article 12) and receive information (Article 13). According to article 28, the states are obliged to make primary education compulsory and available to all children. Children have a right to be registered immediately after birth and to have name and nationality (Article 31) and to protection from all forms of exploitation and sexual abuse (Article 34).
Among the large number of countries that have adopted comprehensive child rights, legislation in their children's act following the birth of the Convention ranks as small a country as Nepal.
Mercifully, notable advances have been made during the last decade of the 20th century and the subsequent years of the present century for the welfare of children, including:
- Laws to safeguard them from suffering and exploitation
- Near eradication of poliomyelitis
- Reduction of morbidity and mortality from neonatal tetanus and measles
- Fall in vitamin A deficiency (VAD) blindness
- Reduction in deaths from diarrheal dehydration
- Sensitization of people against child labor and child abuse and neglect (CAN), etc.
Fig. 1.4: Child rights protection. Convention on rights of the child (1989–1990) promises protection of children's right to survive and develop to their full potential, and affirms children's right to the highest attainable standard of health care.
Today, more children are born healthy and more are immunized, more can read and write, and more are free to learn, play, and simply live as children than would have been thought possible years ago, according to a UNICEF report. This is the direct result of translation of the commitments made in the Convention into concrete action.
Yet, for all the gains made, violations of children's rights, particularly in the resource limited world, continue to be breathtaking, ranging from failure to register births and provide health care and education (Figs. 1.5 and 1.6) to exploitation in the form of child labor, abuse, and neglect (Fig. 1.7), and involvement of adolescents in terrorist and militancy-related armed conflicts. As aptly put by the UNICEF:
- Every day that nations fail to meet their moral and legal obligations to realize the rights of children, 30,500 boys and girls under-5 years die of primarily preventable diseases.
- Every month that the full-scale campaign needed to stop the HIV/AIDS pandemics is postponed, 250,000 children and young people become infected with the fatal virus.
- Every year that governments fail to spend for the basic social services or slash developmental assistance, millions of children across the developing world stand deprived of access to safe drinking water and sanitation facilities as also health and school services that are vital for their survival and growth and development.
Fig. 1.5: Elementary education. Every child's right. Compulsory and free elementary education is one of the 10 fundamental rights of the child to which India too is committed.
Fig. 1.6: Child's right to education and the government. Provision of facilities for free elementary education is the responsibility of the government. However, the onus lies on the parents to ensure that child obtains such an education rather than have him involved in activities that amount to school withdrawal.
Fig. 1.7: Child's right to education and parents. As high as 130 million (21%) primary school age children in the resource-limited world do not attend school out of a total of 625 million children of this age group in these countries, thanks to reasons on parental side.
Undoubtedly, there is a strong case for a social movement to fan the flame that burned years ago for rights of the child and the adolescent for smooth navigation into adulthood. This is particularly a must for advancing human development in the developing countries and those of us responsible for health and care of children and adolescents must in particular take it as a call for vision and leadership to realize a new dream of humankind, free from poverty, disease, and discrimination.
It is pertinent to recall the historic general assembly special session on children, held in 2002 to which, for the first time a large number of children were included as official members of the delegations. True to the spirit of the convention on the rights of the child, the assembly gave a call for considering the views of children and young people when decisions that affect their lives are being made.
CHILD RIGHTS IN INDIA
In India's Constitution, Article 24 prohibits employment of children below the age of 14 years in factories. Article 24 prevents abuse of children of tender age. In Article 45 is incorporated provision of free and compulsory education for all children until they complete the age of 14 years (Figs. 1.5 and 1.6).
Thus, India's Constitution undertakes to guarantee equality before the law, pledging special protection for children.
Subsequent to India's accepting the obligations of United Nations convention on the rights of the child, following are some of the initiatives launched by India toward advancement, promotion, and protection of child rights:
- National commission for protection of child rights.
- National plan of action for children.
- Right to education.
CHILD RIGHTS ADVOCACY AND THE PEDIATRICIANS
More often than not, children are vulnerable and disadvantaged in the society. Undoubtedly, they are in need of a special attention. A global perspective for the field of pediatrics is, therefore, not just desirable, but mandatory.
Since children are usually not in a position to speak out and advocate for themselves, it is the pediatricians who need to advocate for them in order to advance children's well-being and welfare. This applies to all children across the board, regardless of national boundaries, ethnicity, race, religion, culture, and gender. Pediatricians need to create awareness:
- For child's nutrition, growth and development, education and, in fact, overall care so that the child not only survives, but also grows into a healthy adult useful to himself, the family, and the society.
Furthermore, pediatricians need to provide a platform or contribute to it for promotion of coordinated child-centric endeavors with involvement of like-minded groups of social workers, teachers, psychologists, child rights activists, and community leaders. Collaboration with national and international NGOs is useful to positively influence the government to model its policy in keeping with the UN convention on child rights. The scenario in India is not better.
CONTEMPORARY DISEASE PATTERN AND CHANGING CONCERNS
Disease pattern amongst under-5s in India (Fig. 1.9) is at considerable variance with that of developed world (Fig. 1.10). Every year, 70% of deaths in children are due to respiratory infections, diarrheas, measles, malaria or malnutrition. Figure 1.9 gives a rough idea about the disease pattern in patients admitted to our pediatric indoors. With some variations, which are bound to be there from region to region, observations from various parts of India indicate a remarkably similar pattern. This is true of some of our neighboring countries like Bangladesh, Bhutan, Myanmar, Pakistan, Afghanistan, Sri Lanka, Indonesia, and Nepal as well.
Fig. 1.8: Child labor. Gateway to deprivation of child rights to education. Child labor, often encouraged by parents for one or the other reason, is the most important cause of school withdrawal and dropout.
Fig. 1.9: Childhood disease pattern in resource-limited world. Relative frequency of diseases responsible for admission of infants and children in Indian hospitals shows predominance of malnutrition, diarrheal diseases, and infectious diseases. Dotted lines indicate much overlap.
Fig. 1.10: Childhood disease pattern in developed world. Distribution of disease pattern in developed world in the under-5 populations shows predominance of perinatal problems and pneumonias and other infections.
An appraisal of the health statistics makes it clear that the scene is dominated by malnutrition (primarily the so-called protein-energy malnutrition), serious systemic infections (primarily tuberculosis, pneumonias, malaria, and measles), and diarrheal diseases. These have a considerable overlap on each other and, in broad sense, account for 75% of the cases. The remaining of the so many diseases is responsible for a mere 25% of the admissions.
Nutritional deficiency states constitute a major public health problem in India and other resource-limited countries.
Though incidence of severe malnutrition, especially acute severe malnutrition (ASM) in the form of kwashiorkor and marasmus has considerably fallen, mild-to-moderate malnutrition (Figs. 1.11A and B) continues to be a cause of concern. According to the latest National Family Health Survey-4, 38% of the under-5s who are stunted usually remain stunted in subsequent years (Box 1.4 and Fig. 1.12). Major brunt is borne by the periurban (slum) and rural children. Over and above this, there is high incidence of micronutrient deficiencies (the so-called hidden hunger), particularly in relation to iron, vitamin A, iodine, zinc, etc.
Figs. 1.11A and B: Malnutrition a challenge. Notwithstanding considerable decline in incidence of severe malnutrition, mild-to-moderate malnutrition is rampant in Indian children, especially in the rural and periurban settings.
Fig. 1.12: Nutritional stunting. India has the highest number of stunted children followed by Nigeria and Pakistan. Nutritional stunting contributes to reduced physical and cognitive development.
Paradoxically, whereas endeavors are focused on controlling undernutrition, children from affluent families are beginning to suffer from overweight and obesity in a big way (Fig. 1.13). The current prevalence of childhood overweight in India is estimated to be 5–25%. Besides, health consequences of obesity, studies from India and other countries have demonstrated an association between overweight and psychosocial risk factors such as depression, anxiety, and social withdrawal.
India, therefore, appears to be in the thick of what may be termed the “dual burden” of malnutrition. This implies that India is not only struggling with childhood undernutrition, but is also a fast weight gaining nation, heading for enhanced epidemic of lifestyle diseases like obesity, diabetes, hypertension, etc., not only in adults, but also in children and adolescents.
Fig. 1.13: Childhood obesity—a challenge. Of late, obesity in children and adolescents too is emerging as a big challenge in India and other resource-poor countries. It is central to such comorbidities as hypertension, type 2 diabetes, cardiovascular disease, and hyperlipidosis.
Infectious Diseases
Infections are another major cause of pediatric morbidity. With considerable reduction in prevalence of preventable childhood infectious diseases, the dominance is now taken over by respiratory and gastrointestinal infections.
- Acute respiratory infections (ARIs) are responsible for 20–60% of outpatient attendance, 12–45% of admissions and 33% of mortality in the developing world, directly or indirectly. Over 15–20% of preschool mortality is related to ARIs, especially pneumonias.
- Though polio and neonatal tetanus stand eliminated, measles continues to cause considerable morbidity and mortality in India and other World Health Organization (WHO) SEAR countries.
- WHO is committed to eliminate measles in whole SEAR by 2020. To achieve the goal in India, GOI has introduced two-dose strategy for measles vaccine in routine immunization. According to IAP, it is advisable to give measles vaccine as a component of measles and rubella (MR), even when it comes to first (9 months) dose rather than alone to provide extended benefit.
- Childhood's tuberculosis and malaria and other mosquito-borne infectious diseases continue to be rampant.
- Emerging and re-emerging infectious diseases too are a threat.
Diarrheal Diseases
Diarrheal diseases constitute yet another leading cause of morbidity and mortality. Almost 500 million children suffer from acute diarrhea annually. Of them, 5 million die every year. 11In India alone, nearly 1.5 million children become a casualty due to acute diarrhea every year. Widespread use of oral rehydration salt/solution (ORS) has led to decline in morbidity and mortality. However, incidence of diarrheal disease continues to be high in the underprivileged sections.
The Camel-back Concept
As is obvious, the book picture of a disease is less likely to be seen in our practice and circumstances. A 6-year-old, presenting with acute dysentery, may have significant malnutrition also. To cap this, he may have pulmonary tuberculosis. That is not the end, however. Such a child, as we have often seen, may have one or more intestinal parasitic infestations and skin infections like scabies and pyoderma.
Thus, one finds a multiplicity of ailments in a single child. This kind of a patient has been compared to a camel-back.
This observation has been made by us and by others in this country and also in other developing countries where people continue to be underprivileged. This consideration, in particular has contributed to the launching of Integrated Management of Childhood Illness (IMCI) scheme by the WHO and UNICEF. The program has already assumed the status of a dominant child health and welfare program in India. A brief deliberation on the strategy is presented in Chapter 9 (Community Pediatrics).
Emerging Issues
Mercifully, there is a greater appreciation of the emergence of such newly recognized problems such as HIV/AIDS, drug abuse among teenagers, child abuse and neglect (CAN), street children, child labor, discrimination against girl child, etc. and need to meet their challenge.
HIV/AIDS alone appears to be threatening to nullify all benefits from national health programs aimed at welfare of children.
Unfounded Beliefs: A Roadblock
What is particularly disappointing in relation to the developing world is that, notwithstanding, considerable advancements in virtually all fronts, illiteracy, ignorance, superstitions, ambiguous and unfounded cultural and religious practices and rituals continue to have considerable influence in the area of health and nutrition.
Howsoever incredible it may seem, many folks still think diseases are the “outcome of the curse”. Quite a proportion of them rely on witchcraft for their treatment. In a pilot study, we found that 40% of the slum parents believed that the disease can be caused by the wrath of deities (supernatural beings), a posthumous world of dead ancestors and magical concepts.
Quality of Life
The quality of life in the Indian subcontinent is generally not up to the mark. Almost one-third of the pediatric population has a deplorable existence. About one-half of our children can be classified as unhealthy and surviving with impaired bodies and, perhaps, intellects. Various interrelated conditions such as malnutrition, diarrheal disease, infections like tuberculosis, acute respiratory infection (ARI), parasitic infestations, etc. contribute to ill health and poor growth. Over 50% of children are undernourished. The most vulnerable period for malnutrition is first 3 years (usually 6 months to 2 years) of life. The consequences of too many mouths-to-feed and the lack of fool-proof system of health care with an accent on the rural and the urban poor and other social services against a backdrop of generally poor socioeconomic status further aggravate the situation.
In a nutshell, admittedly, climatic, geographical and ethnic factors play some role for the remarkable difference in disease pattern between Indian subcontinent and rest of the developing world and developed world. However, of much greater significance are factors like socioeconomic conditions, hygiene and sanitation, culture, education, and local medical and health facilities. Indeed, these need consideration and thrust of the policy-makers and think-tanks.
MORTALITY SCENARIO AND DELIVERY OF CHILD HEALTH CARE
Box 1.5, Table 1.2, and Figures 1.14 and 1.15 give a broad idea of the under-5 mortality scenario in the developing world.
Today, a child in India has far better chances of survival with the life expectancy of around 68 (males 67.3, females 69.6) than three or four decades back. However, the situation is still far from satisfactory.
- The current IMR of 32 per 1,000 live-births (from 129 in 1970) is still many times higher than in the advanced countries (Table 1.2). Vast state-wise variations are noteworthy with Goa and Kerala having IMR of 8 and 13, respectively and UP/Odisha and Rajasthan having IMR of 61 and 55, respectively. Likewise, urban India has much lower IMR compared to rural India. The rapid fall in IMR in the recent years is in line with the UNICEF's projections. However IAP's ambitious target, Mission 20:20 (IMR 20 at 2020) stands unattained.
- Perinatal mortality (a reliable index of status of women and their health and the quality of antenatal, natal and neonatal care) of 18/1,000 livebirths in India is still higher than 10–15 in most developed countries. It is estimated that three perinates die in India every minute amounting to a huge human wastage of 1.5 million perinates every year. Likewise neonatal mortality rate (NMR) is 23/1,000 live births compared to a figure of 1–4/1,000 live births in prosperous countries. About 60% of the infant mortality is accounted by neonatal deaths. GOI is committed to achieve a single digit neonatal mortality rule (NMR) by 2030.
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Fig. 1.14: Under 5-mortality scenario. Note that around 40% of total mortality is constituted by the neonatal deaths followed by lower respiratory tract infections (pneumonias), diarrhea, and malaria.
Fig. 1.15: Neonatal deaths. In India, with neonatal mortality rate being still high (23/1,000 livebirths), neonates contribute to around 40% of the under-5 mortality rate.
Factors responsible for continued high (though reduced) perinatal/neonatal mortality include:
- Vicious cycles of frequent pregnancies
- Compromised maternal health and nutrition
- High incidence of low birth weight and, in consequence, poor perinatal survival
- Poor perinatal care.
Perinatal care is often very unsatisfactory. When available, it is availed of only by a proportion of the mothers because of illiteracy, ignorance, and cultural and social bias.
It is now widely accepted that significant gains as far as IMR are concerned are due to fall in postneonatal deaths as a result of availability of Integrated Child Development Services (ICDS) scheme, usual interstitial pneumonia (UIP), acute respiratory infection (ARI), vitamin A prophylaxis programs, etc. Since perinatal mortality, accounting for 60% of the IMR, remains only marginally altered, it has become increasingly difficult to remove stagnation in the IMR (at present 32). This factor apparently contributed to India's failure to meet the millennium goals by the year 2015.
According to one estimate, chances of a newborn attaining the age of 5 years in India are the same as reaching the age of 50 or 60 years in the prosperous countries. The preschoolers form about 17% of the population, but are responsible for over 40% of the total mortality. 13Notwithstanding the developments of the past decade, under-5 mortality, infant mortality, neonatal mortality, and perinatal mortality rates are still unacceptably high. Notably, mortality rates in rural and periurban areas are nearly double of those in urban areas.
HIGH MORBIDITY AND MORTALITY: CAUSE AND SOLUTION
Let us have a peep into the real cause of high morbidity and mortality in children in India.
- Whereas in advanced countries 5–12% of the gross national product (GNP) is reserved for health services, only 2% of India's GNP is allocated for this vital area.
- Maternal and neonatal care, though well-accepted, is crying for yet more and solid attention. With the exception of tetanus toxoid prophylaxis, iron-folate tablets, and training of the traditional birth attendants (TBAs), no truly concrete program was indeed available for neonates and pregnant women until end of the 20th century. Of course, situation is gradually beginning to change for the better.
A survey conducted in 1976 by us showed that 93% of the teaching institutes in India are not adequately equipped with neonatal care facilities. A follow-up survey in 1985 and yet another in 1992-93 showed only marginal improvement in the state of affairs. Another survey conducted by the National Neonatology Forum (India) pointed out that almost three-fourths of the hospitals are not equipped with even the basic tools of neonatal care, like low-reading rectal thermometers, oxygen head boxes, resuscitation equipment, exchange transfusion sets, and incubator/open care system. The neonate is regarded as only a byproduct of conception. He is seldom entitled to a status of a bed in the ward.
According to the preliminary results of our most recent survey, well-meaning child-friendly developments over the last decade or so are beginning to transform the pediatric scenario in the country to one of expectancy. Neonatal care, for instance, has witnessed considerable improvement in India with opening of neonatal intensive care units across the country (Fig. 1.16). However, as yet the development is by and large limited to the urban sector, warranting its extension to the rural sector.
Fig. 1.16: Of late, neonatal care has witnessed considerable improvement in India with opening of neonatal intensive care units in many parts of the country. However, it is by and large limited to the urban sector.
Besides the inadequacy of the health strategy, unfavorable factors like rising population, lack of resources, poverty, ignorance, and illiteracy have contributed to the sad state of health of our children.
Logically, therefore, the solution lies in the health services going to them rather than other way around. No wonder that this also requires active participation of the communities which should learn to protect themselves from disease and seek help as and when they need it. There is also need to increase the health budget which at present is inadequate.
FROM MILLENNIUM DEVELOPMENT GOALS TO SUSTAINED DEVELOPMENT GOALS IN INDIA'S CHILD CENTRIC INITIATIVES
As duly emphasized by the UNICEF, development begins with the child. Children's welfare measure lead to every aspect of the development of a nation—economic, social, and political. India has fared well in meeting certain child-related development goals.
With this background, in September 2000, India along with 188 other nations signed the United Nations Millennium Declaration, committing to eradicating extreme poverty in all its forms by 2015.
To help track progress toward these commitments, a set of time-bound and quantified goals and targets, called the Millennium Development Goals (MDG), was developed to combat poor economic status in its many dimensions.
The MDGs included 8 goals, 21 targets, and 60 indicators for measuring progress in the 15 years between 1990 and 2015, when the goals were expected to be met.
Unfortunately, except for MDG 4 to reduce child mortality, and MDG 5 to reduce maternal mortality, other MDGs remained only partially realized by 2015 in India. Similar had been the story in several other countries.
In order to ensure continuation of the initiatives, the WHO extended the MDG under the Sustained Development Goals (SDG) with 2030 as the target year. Among the 13 goals set to be attained by 2030 are the two robust goals concerning India:
- Reduction in neonatal mortality to 12 (at present it is 22)
- Reduction in under-5 mortality to 25 (at present it is 38).
FETAL ORIGIN OF ADULT DISEASE: A CHALLENGE
The famous Barker's hypothesis, after David Barker (Fig. 1.17), linking the adult diseases to fetal period, now appears to be holding good in entirety. Evidently, we are in for the fresh challenges.
According to Barker's hypothesis, the impact of impaired intrauterine growth and development does not restrict itself to infancy, childhood, and adolescence. Its consequences go much beyond that. In other words, roots of adult disease arc laid during fetal life only.14
Fig. 1.17: David Barker (1938–2013). A physician and epidemiologist, known for the famous hypothesis after his name, believed in the protection of nutrition of young mothers and babies-in wombs as a safeguard against adult disease.
For instance, impaired fetal growth and development (low birth weight, for instance) may well predispose to development of cardiovascular (hypertension, ischemic heart disease, and stroke), endocrine (type II diabetes), and metabolic (obesity) diseases during adulthood.
During critical periods in early fetal growth and development, there are persisting changes in the body structure and function that are caused by environmental stimuli—the so-called programming. This relates to the concept of developmental plasticity where our genes can express different ranges of physiological or morphological states in response to the environmental conditions during fetal maturation.
Even today, diseases such as diabetes, hypertension, coronary artery disease, obesity, metabolic syndrome etc. are being increasingly diagnosed not only in adults, but also in young children and adolescents. However, chances are that there may well be yet bigger outbreaks of these preventable diseases in the foreseeable future.
It is a paradox that India, now in the thick of overwhelming problem of undernutrition, is heading for a peculiar situation of epidemic of dual burden of undernutrition on one hand and overweight and obesity on the other hand.
The community needs to be forewarned about the fetal origin of adult diseases. There is a dire need to increase awareness about the impending explosion of epidemics of these diseases. Research and deliberation on the prevention and early diagnosis of these diseases employing simple and affordable strategies are also warranted.
PEDIATRIC EDUCATION
Pediatric education, the art of imparting knowledge about child health, in the resource-limited world cannot be on the same lines as in the developed world since the needs of children in the two worlds are not the same. For example:
- Pediatricians in the West face newer problems like inborn errors of metabolism, fetal anomalies, genetic counseling, adolescent substance abuse, obesity, etc.
- In the developing countries, on the other hand, the priorities are malnutrition, diarrheal disease, and infections such as ARI, tuberculosis, and intestinal parasitoids, as also low birth weight infants.
Training in pediatrics in these countries needs a relatively greater focus on clinical diagnostic skills and affordable therapies rather than on sophisticated investigations and expensive therapeutic modalities.
Currently, thanks to the concerted efforts of the IAP, the sole representative body of India's nearly 25,000 qualified pediatricians and a guardian of the specialty in the country, pediatrics now holds the status of an independent discipline, both in undergraduate medical teaching and university MBBS examinations. As a result, pediatrics is being taught to the medical students on par with adult medicine, surgery and obstetrics, and gynecology. The major beneficiary, directly or indirectly, is undoubtedly our child population. A significant number of books published from India by the Indian experts, focusing on priority problems of the Indian subcontinent, have contributed to pediatric education and its application in practice (Fig. 1.18).
There is a considerable merit in the suggestion that the growth and development component of pediatrics be introduced in the preclinical years of the undergraduate career.
Today, opportunities for postgraduation are available not only in general pediatrics, but also in a few of its subspecialties. It is felt that the Medical Council of India (MCI) must initiate action to develop uniformly standard curriculum as also uniform system of examination in case of the pediatric postgraduates as well. The task needs to be accomplished in the first quarter of the 21st century rather than allowed to catch dust for another few decades.
Fig. 1.18: Pediatric education. Publication of several pediatric books from India by Indian experts has considerably contributed to pediatric education and its practical application for the community at large.
TOWARD BETTER TOMORROW
To cut the long story short, the greater attention on the whole child—not just the childhood ailments—can go a long way in promoting family welfare and checking enormous population explosion. As soon as people are convinced that their children are going to survive and grow into healthy adults, the temptation to have too many issues will decline.
The pace of practical implementation of Government's professed policy has got to be drastically accelerated. This needs a political will and commitment rather than sheer slogans and paperwork, as also augmentation of the health budget. There is no place for lopsided priorities.
The best pediatric slogan should be:
Not many, but healthy children, if we are keen on having a happier nation.
Box 1.6 lists some of the significant medical advances that are likely to contribute to mitigating medical problems of children in the developing countries such as ours.
To the conservative reader, this may sound rather premature. But, mind you, what we have in mind is the projected scenario a decade or two ahead.
To conclude, let us modify in context of child health what the celebrated critic and writer, John Ruskin (Fig. 1.19), said some 150 years ago:
I hold it indisputable that the first duty of a State is to see to it that every child is well-housed, clothed, fed, educated, and kept fit.
The time to act is now. Today. Yes, right away!
For, as the poet, Gabriela Mistal, put it (Fig. 1.20):
Many of the things we need can wait. The child cannot. His name is Today. To him we cannot answer tomorrow.
The onus lies on the pediatricians and pediatricians-in-the-making, nay all professionals involved directly or indirectly in preventive and curative child health care to ensure that each and every child attains his development and potentials in full. This is the key gateway to happy and healthy childhood and adolescence (Fig. 1.21), finally leading to productive adulthood.
Last but not the least, there is a need for the India's NITI Aayog and think-tanks for further deliberations on India's execution of its strategy to deliver health to children in a vast country remarkable for diversity and logistic bottlenecks and roadblocks. Let's hope, we successfully fulfill the unmet or inadequately met goals in the near future.
Fig. 1.19: John Ruskin (1819-1900) was of the firm conviction that every child needs to be well-housed, clothed, fed, educated, and kept fit.
Fig. 1.20: The Latin American Nobel Laureate, Gabriela Mistral (1889–1957) who observed: The child cannot wait His name is today. To him we cannot answer tomorrow.
Fig. 1.21: Healthy and happy children. All endeavors related to pediatrics should aim at healthy and happy children who grow and develop as productive adults useful to themselves, to the families, and the community at large.
1. Mission Indradhanush has a target of vaccination coverage of 90% by 2020 in each of the following infectious diseases, except:
- Tuberculosis
- Chickenpox
- Polio
- Diphtheria, tetanus, and pertussis
- Measles
- Hepatitis B
2. Spot the wrong observation:
- Pediatrics now covers the period from conception through adolescence
- Current infant mortality, neonatal mortality, and perinatal mortality rates in India are around 32, 23, and 18, respectively
- Currently, India's health budget is 1.5% of the total budget
- National Health Mission now stands extended to urban areas as well
3. The date, 14th November, is observed as “Chacha Nehru Day” in India. Which day is observed as “Universal Children's Day”?
- 14th November
- 1st January
- 2nd October
- 30th January
4. Which of the following observations about disease pattern and mortality in under-5s is correct?
- In resource-limited world, predominance of malnutrition, diarrheal diseases and infectious diseases
- In developed world, predominance of perinatal problems, pneumonias and other infections
- Three top killers of under-5s in developing regions are the trio of “malnutrition, diarrheal disease, and infectious diseases”
- Though mortality from childhood diarrhea has considerably come down, incidence of diarrhea continues to be high, especially in resource-limited communities
- All of the above
5. According to the gist of the Barker's hypothesis, origin of adult disease dates back to the fetus. Which of the following is not a part of Barker's hypothesis concerning LBW and IUGR?
- Insulin resistance syndrome
- Lipid, clotting factors, and cardiovascular dysfunction
- Obesity
- Short stature
1. B | 2. C | 3. A | 4. E | 5. D |
FURTHER READING
Journal Articles/Book Chapters/Internet
- Fernandes N, Khubchandani J, Seabert D, et al. Overweight status in Indian children: Prevalence and psychosocial correlates. Indian Pediatr. 2015;52:131–134.
- Government of India. Ayushman Bharat Yojana. Available from https://www.pmjay.gov.in/. [Last accessed June 2019].
- Patcher LM. Overview of pediatrics. In: Kliegman RM, St Geme III JW, Blum NJ, et al (eds). Nelson Textbook of Pediatrics, 21st edn. Philadelphia: Elsevier 2020: 1–8.
- Tiwari SK, Kale P. Maternal nutrition and fetal health and outcome. In: Gupte S (ed). Recent Advances in Pediatrics (Special Vol. 20: Nutrition, Growth and Development). New Delhi: Jaypee 2009:1–17.
- World Health Organization. 2018 Health SDG Profile India. Available from http://www.searo.who.int/entity/health_situation_trends/cp_ind.pdf?ua=1. [Last accessed June 2019].
Books/Monographs
- Barker DJP. Fetal and Infant Origins of Adult Disease. London: BMJ Books 1992.
- Government of India. A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India. New Delhi: Ministry of Health 2013.