Common Health Problems

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Low birth weight

The birth weight of babies born to well nourished mothers is usually about 3.5 kg. But the average birth weight of Indian babies is 2.7 to 2.9 kg. It’s very important to record the weight of the baby within one hour of birth. It determines the growth and chances of survival of the baby.

The low birth weight internationally has been defined as a birth weight of less than 2.5 kg (up to and including 2.499 kg) the measurement being taken preferably within the first hour of life, before significant post-natal loss has occurred. The baby may be born full term or pre term. There are two types of low birth weight babies.

1. Pre- term babies - Those babies who are born prematurely or before time i.e. 37 weeks of gestation. Their intrauterine growth may be normal i.e. their weight, length and development may be within normal and development within 2 to 3 years of age with proper care during neonatal period and care thereafter. In developed countries, most of the low birth babies are preterm babies. The pre-term deliveries are often due to multiple pregnancy, severe infections, toxemia, teenage pregnancy, hard physical work etc and in many cases the cause may not be known.
2. Small for date (SFD) - Those babies may be born at term or pre-term. Their weight is less than 10th percentile of the gestational age. They are due to related foetal growth. The majority of the low birth weight babies in developing countries are small for date. There are many factors, which are associated with this category of LBW babies. These include in relation to mother, foetus and placenta. Mother related factors are malnutrition, severe anaemia, very young age, short stature, multipara (mother had many earlier pregnancies), close birth spacing hypertension, toxemia, and malaria. Most of these causes are associated with low social-economic and education status of women and people at large. The foetus related factors are: multiple gestation(twins or triplets), intrauterine infections, foetal abnormalities and chromosomal abnormality. The placental related factors include placental abnormalities and insufficiency.

Infectious diseases

There are number of infectious diseases which are common among children and are the cause of high mortality in them. These include diarrhea, acute respiratory infections (ARI). Measles, pertussis (whooping cough), diphtheria, polio, tetanus and tuberculosis.

Accidents and poisoning

Accidents and poisoning are quite common in children because of hazards in home, on the roads, schools etc. they are prone to get burns, injures, drowning, poisoning, falls, electric shock, road accidents etc.

Child health care

Child health care refers to care of children from conception to birth and after birth till the age of five. After the age of five, the child’s health is taken care by school health programmer team. Health workers working for MCH services may or may not be the part of school health team.

The health of the child, in fact starts with the birth of girl child who is the future mother of the child. Child health care services include health care of the fetus before birth (ante-natal pediatrics), health care of neonates from birth to 28 days, care of infants from one month to 12 months, care of toddlers from one year to two years and care of pre-school child from two years of age. The objectives of child health services are to ensure that:

• Every child receives adequate care and proper nourishment.
• Their growth and development is monitored and any deviation is identified and treated on time.
• Ailments are detected and treated without any delay to prevent it from getting worse.
• Trained persons render care.
• Mothers and family members are educated and trained to give proper care to their children to promote their health.

The health care of children in various stages of childhood is presented here.

Care of foetus

One of the objectives of care during pregnancy is ‘to ensure the birth of mature, live and healthy baby’. The focus of antenatal care is thus not only to promote health of mothers and prevent complications in mothers, but also to prevent low birth weight, foetal disorders, neonatal asphyxia, congenital anomalies etc. in the foetus. Care of foetus also refer to antenatal pediatrics.

Low birth weight and many abnormalities can be prevented and normal growth and development can be promoted to quite an extent by adequate and proper antenatal care, nutrition etc. Adequate and proper care including family planning before pregnancy also helps.

Care of neonates

Care of newborn baby includes from birth to 28 days. The care during this period is very important because it helps in reducing postnatal and neo-natal mortality. The care during this period is rendered by a team comprising of obstetrician, pediatrician, nursing personnel. The care during the first week after birth and especially during the first 24-48 hours is very crucial because this period is very critical as lapses during this period can cause serious problems resulting in high mortality, proper care on neonates help prevent 50-60 percent of all infant deaths and more than half of these can be prevented during the first week of their life.

Neonatal Jaundice

What is Neonatal Jaundice

Yellowish staining of the skin and whites of the newborn's eyes (sclerae) by pigment of bile (bilirubin) is termed neonatal jaundice. In newborn babies a degree of jaundice is normal. It is due to the breakdown of red blood cells (which release bilirubin into the blood) and to the immaturity of the newborn's liver (which cannot effectively metabolize the bilirubin and prepare it for excretion into the urine). Normal neonatal jaundice typically appears between the 2nd and 5th days of life and clears with time. Neonatal jaundice is also referred to as neonatal hyperbilirubinemia and physiologic jaundice of the newborn. It may last till 8 days in normal birth or around 14 days in premature births.

Symptoms

1. Yellow skin
2. Yellow sclera and nail beds
3. Baby sleeps for a longer time than usual

Care

If the jaundice is mild, it clears on its own in 10 days of time. However, it is mandatory to follow these treatments in order to reduce the severity.

1. Breastfeed the baby more often.
2. Exposure to indirect sunlight. Preferably place the cot or the cradle of the baby next to the window with a thin screen.
3. Place them under bili lights (a photo therapy tool) to expose them to high level of coloured light to break down the bilirubin. Blue light is usually used for this purpose. Green light is more effective in breaking down bilirubin. However it is not commonly used as the babies start appearing sick
4. In severe conditions blood is transfused
5. Use of specific drugs to stimulate the liver to get rid of the yellow pigment

Note: If jaundice continues beyond 2 weeks, then newborn metabolic screen should be checked for galactosemia and congenital hypothyroidism. Family history should be explored with the evaluation of infant's weight curve. Stool colour should also be assessed.

Care of infants, toddlers and pre-schoolers

The infant, toddlers and preschoolers together can be categorized as under five children. In fact, these are defined stages of growth and development of less than five years. The care of all these age group of children is discussed simultaneously from convenience point of view. It is also felt that the care is continuous care from one age group to another and the components of the care are same. The care is given by the same team of the health personnel in health centers and clinics in the hospitals and is discussed as care under five children.

Monitoring of growth and development

It is very important to monitor growth and development of children regularly. It indicates health and nutrition status of the child. It helps in identification of any deviation from normal growth and development and timely corrective measures can be taken at the family and health center level.

Growth of child

Growth of the child refers to increase in size of the body, which is measured in terms of body weight, height (length of the baby) head, and arm and chest circumference. These measures are called ‘anthropometrics’ measurements. These measures are compared with the reference standards to assess whether the measure is within the normal limits or not (+ or – 2 standard deviation). The measures can also be assessed in terms of percentile i.e. percentage of individuals falling below a particular level e.g. 50th percentile limits are considered as 3rd percentile and 97 the percentile. The weight of the children (94%) falling between these two limits considered within normal range.

Indian council of Medical Research (ICMR) sets up the reference standards for Indian children by going cross-sectional studies. Reference standards are also set up by WHO can be used for under five children anywhere in the world.

The growth chart has many advantages. It can help in:

• Regular recording of weight and monitoring of growth of the child with the active participation of mother.
• Identifying level of malnutrition in children
• Taking recommended action according to specific grade of malnutrition
• Education of mothers and health workers about the importance of regular weight taking and prevention and control of malnutrition.
• Making assessment of the effectiveness of remedial measures for malnutrition in children.

Pattern of growth

The growth in children varies in different age groups and may vary in children in each age group depending upon various endogenous and exogenous factors. The growth of children follows a definite design/course with references to anthropometric measurements, which is discussed in brief underneath. In normal, healthy and well-nourished children rapid growth takes place during the first year of life.

Weight: Almost all babies lose weight during the first 3 to 4 days of birth and regain weight by 7 to 10 days. The increase in weight is 25-30 gms per day for the first three months, thereafter the increase is less rapid. Normally, the baby doubles its birth weight by five months and triples it one year, except for low birth weight babies.

The low birth weight babies double their weight earlier and quadruple their weights in one year. After one year, the increase in weight is not very fast.

The weight curves of many children are very good for the first five to six months with the birth weight doubling by this age. But after this age the growth curve tends to falter i.e. go unsteadily. This is because the breast feeds alone are not sufficient for the child. Breast feeds need to be supplemented by additional food items discussed earlier.

The weight of the child depends upon his/her height. It is very important to determine whether the weight of the child is in normal range or not. The child’s weight can be overweight or underweight for height. The underweight for height indicate emaciation or malnutrition.

Height: The height is another measurement of growth of the child. The height of the new born baby is 50 cms (20 “). The height increase during the first year is 25 cms. , in the second year 12 cms. In 3rd, 4th and 5th year the increase is 9cms, 7cms, and 6cms, respectively. If the height is less for age. It refers to stunted growth. Unlike weight, height is not affected by malnutrition immediately. Chronic malnutrition affects it over a period in the past. It is very important to record height very accurately.

Head circumference and chest circumference: - These are also the measurements of growth the head circumference at birth is about 34 cms (14”). It is about 2 cms more than chest circumferance. The chest circumference increases further and becomes more than head circumference. If the child is malnourished, the overtaking of chest circumference is delayed by 3 to 4 years.

Mid-arm circumference: This is an easy and useful measurement; the middle of the upper arm is measured while it is hanging relaxed at the side of the body. The tape is directly placed gently but firmly without compression of the soft tissues round the midpoint. There is rapid increase in the circumference from birth to 1 year: the increase is from about 11cms to 12 cm. These after till 5th birthday it remains fairly constant at about 16-17 cms in well-nourished children. During this period muscles replace the fat of early infancy. A measurement below 80 percent of normal i.e about 12.8 cms indicates moderate to severe malnutrition. A colored strip for measuring arm circumference is available.

Development of the child

The development of the child refers to development of skills and functions related to intellectual, emotional and social aspects. This refers to psychosocial behavioral developments, it is therefore important not only to monitor the growth pattern of children but also monitor their developments. For this it is necessary to be familiar with some of the important landmarks of milestones of developments. There is a normal range for achievement of milestones and therefore achievement of milestones differs in children. Health workers must make observations of growth and mile stones and also must educate mothers and family members about growth and development of children so that they can also be guided in developing healthy habits in their children.

The growth and development of children is influenced by various factors. These factors includes: biological endowment like genetic inheritance, age sex, nutrition of mother and child after birth onwards; physical environment like-good housing conditions sunlight, safe water supply, prevention and control of infections like diarrhoeal diseases etc. . Family welfare aspects like family size, birth order and birth spacing, care during pregnancy. Most of these factors are under the direct influence of socio-economic status of families and women in particular. In order to promote normal growth and development it is important to consider all these factors, which have direct influence on growth and development of children.

Diarrhoea

A child has diarrhoea when there is a change from normal bowel habits to more frequent and looser or watery stools. The stools are often foul smelling. During the diarrhoeal episodes the baby becomes sick, irritable and/or lethargic. Most diarrhoea is self-limiting and last for 2-3 days.

Danger signs of diarrhoea

The major concern in diarrhoea is rapid fluid loss resulting in dehydration. Any significant dehydration constitutes an emergency, so be aware of the following signs:

• Excessive thirst / irritability
• Sunken eyes
• Dry lips, tongue and skin
• Decreased amount of urine
• Very frequent passage of watery stools
• Lethargy or poor oral acceptance of fluids
• A child with any of the above signs should be shown to a doctor without delay
• Consult the doctor also if the child has blood in his stools. This is dysentery and child requires to be given medicines for this.

Prevention of diarrhoea

Diarrhoea can be prevented by simple measures like:

• Drinking clean drinking water
• Exclusive breast feeding for first 6 months
• Avoid use of bottle for feeding the infant
• Frequently washing the child‘s hands, washing hands before preparing food and cleaning the child after he has passed stools
• Keeping food articles covered
• Giving only freshly prepared food to the child. Any food that is left over from a previous meal should not be given to the child again at the next meal
• Avoiding consuming food prepared and served in unhygienic conditions

Oral Rehydration Solutions - the most effective, least expensive way to manage diarrhoeal dehydration.

To prevent too much liquid being lost from the child's body, an effective oral rehydration solution can be made using ingredients found in almost every household. One of these drinks should be given to the child every time a watery stool is passed.

Ideally these drinks (preferably those that have been boiled) should contain:

1. Starches and/or sugars as a source of glucose and energy
2. Some sodium and
3. Preferably some potassium

The following traditional remedies make highly effective oral rehydration solutions and are suitable drinks to prevent a child from losing too much liquid during diarrhoea:

1. Breast milk
2. Gruels (diluted mixtures of cooked cereals and water)
3. Carrot Soup
4. Rice water - kanji

A very suitable and effective simple solution for rehydrating a child can also be made by using salt and sugar, if these ingredients are available. If possible, add 1/2 cup orange juice or some mashed banana to improve the taste and provide some potassium.

Recipe for home-made salt and sugar solutions

For preparing one litre oral rehydration solution (ORS) using salt, sugar and water at home, mix an oral rehydration solution using one of the following recipes; depending on ingredients and container availability:

1. One level teaspoon of salt
2. Eight level teaspoons of sugar
3. One litre of clean drinking or boiled water and then cooled 5 cupfuls (each cup about 200 ml.)

Stir the mixture till the salt and sugar dissolve. An efficient and effective homemade remedy to be used when watery diarrhea strikes and is a good substitute for oral rehydration salts

Related Resources

1. Caring for newborns and children in the community: A training course for community health workers: caring for the newborn at home
2. Jansankhya Sthirata Kosh (JSK) (National Population Stabilisation Fund)