MAGNITUDE

OF
MATERNAL
AND
CHILD HEAL
TH
PROBLEMS
ANDFACTOR

S
INFLUENCIN
G
MATERNAL
AND
CHILD HEAL
TH

SUBMITTED
TO
SUBMITTED
BYMs

SEMINA
R ON
. Subhashini.
G. Mrs.
Santoshi
ShresthaHOD
OBG

Department I
year M.Sc
NursingBangal
ore
Bangalore PA
DMASHREE
INSTITUTE
OF

NURSINGBA
NGALORESE
PTEMBER,
2009

MASTER
PLAN
SUBJECT

: OBSTETRIC
AND
GYNAECOL
OGICAL NUR
SING
UNIT
:

ONE
TOPIC :
MAGNITUDE
OF
MATERNAL
ANDCHILD
HEALTH
PROBLEMSA

NDFACTORS
INFLUENCIN
G
MATERNAL
AND CHILD
HEALTH
DATE

:NAME OF
THE
STUDENT
:
MRS.
SANTOSHI
SHRESTHA

NAME OF
THE
SUPERVISO
R
:

MS.
SUBHASHINI
G.

SL.NO.CON
TENT
1INTROD
UCTION2
TERMMI

NOLOGIE
S 3CONTENT
1.
MAGNITUDE
OF
MATERNAL
AND CHILD

HEALTH
PROBLEMS
Definition and
Meaning of
Maternal and
Child
HealthDefinition
and concepts of
Maternal Health/

Reproductive
HealthObjectives
of Maternal and
Child
HealthGoals of
Maternal and
Child Health
Services

A.Maternal
Health
Problems
I.Nutritional
Problems b)Mal
nutritionc)Nutri
tional
AnemiaII.
Infection

Problemsa)Repro
ductive Tract
Infections (
RTIs)/ Sexually
Transmitted
Infection
(STI) b)Infectio
n in
generalc)Puerpe

ral SepsisIII.
Disturbances and
MenstruationIV.
Mature
GravidasV.
Adolescent
GravidaVI.
Adolescent
Parents

ProblemsVII.
Unregulated
FertilityVIII.
AbortionsIX.
Complications of
DeliveriesX.
InfertilityXI.
Uterine
ProlapseXII.

Cancer of the
Service

B. Child
Health
Problems
I
. Nutritional
deficiency
Problemsa)

Malnutritionb)
Vitamin
Deficiencyc) Iron
Deficiencyd)
Low Birth
WeightII.
Infectious
Diseasesa)Tuber
culosis b)Dipht

heriac)Pertussis
(Whooping
Cough)d)Tetan
use)Poliomyeli
tisf ) M e a s l e s g)
Acute
Respiratory
Infection (ARI)h)
Diarrhoeal

DiseasesIII.
Problems of
Neonatesa)Hype
r
bilirubinemia b)
Hypothermiac)
Neo-natal
tetanusd)Birth
asphyxiae)Oral

thrushf ) s e p s i s
g)The infected
New Born

2. FACTORS
INFLUENCI
NG
MATERNAL

AND CHILD
HEALTH
Maternal Age
Sexuality Factor
Nutrition

Environmental
Factor
Psychological
Factor
Ethnic and Socio
Cultural Factor
Lifestyle Factor

Gender

4
CONCLUSIO
N5 J O U R N
AL
ABSTRAC
T6BIBLI

OGRAPH
Y

MAGNITU
DE OF
MATERNA
L AND
CHILD

HEALTHP
ROBLEMS
ANDFACT
ORS
INFLUENC
ING
MATERNA

L AND
CHILDHEA
LTHINTRO
DUCTION
Maternal and
Child Health
Maternal and
child health is

recognized as one
of the significant
components of
FamilyWelfare.
Health of both
mother and
children is a
matter of Public
Health concern. It

isalso being
observed that the
deaths of mothers
and children are
the major
contributorsto
mortality in any
community in
India. In India

125,000 (460 per

100,000 live
births)women die
due to pregnancy
and child birth
related causes.
About 1.8 million
(74 per 1000 live
births) infants

and 2.65 million

(109 per 1000
live births) under
five childrendie
every year.Health
of mothers and
children is very
important for
acceptance and

practice of
familynorms to
stabilize
population.Mater
al and Child
Health care
services are
essential
andspecialized

services because
mothers and
children have
special health
needs which
arenot catered to
by general health
care
services.Moreove

r, children are
the asset for the
family,
community and
nation. They are
their future.
Whereas
mothers have an
important role in

their growth and

development.Mo
thers health
status during
pregnancy and
after delivery
determines
health status
of child.

Therefore health
care of mothers
and children
occupies an
important place
in our health care
delivery system
and is integrated
part of Primary

Health Care.The
problems of
maternal and
child mortality
are complex,
involving
womens
status,education,
employment

opportunities and
the availability to
women of basic
rights
andfreedom.The
maternal health
status differs
tremendously
from place to

place and in the

same place. It is
assessed in terms
of maternal
health problems
(maternal
morbidity)
andmaternal
mortality. The

factors which are

responsible for
maternal health
problems
i.e.maternal
morbidity and
maternal
mortality
include poverty,

ignorance,
illiteracy,malnut
rition, age at
marriage and
pregnancy, the
number and
frequency of
child bearing and
the number of

unwanted
pregnancies and
abortions, lower
status and
worthof women
in society, lack
of access to
quality maternal
health/

reproductive
healthservices,
gender
discrimination.

TERMINOL
OGIES

M a g n
i t u d
e :
Largeness,
Importance
M o r t
a l i t
y :

Quality or state
of being subject
to death,number
of deaths in
relation to a
specific populatio
n, incidence.

M o r b
i d i t
y :
Condition of
being diseased,
Number of causes
of disease or sick
person
inrelationship to a

specific
population,incide
nce.
I
a
t

n
n
:

A child who is
under 1 year of
age
Sexuality :
The part of life
that has to do
with being
maleor female

Sexually
Transmitted
Disease:
Disease acquired
as a result of
sexual
activitywith an

infected
individual.
D e l i
v e r
y :
Expulsion of a
child with the

placenta
andmembranes
from the mother
at birth
F e r t
i l i t
y :

Quality of being
able to reproduce.
Neonatal
Mortality
:
Statistical rate of
infant death
during the first28

days after live

birth, expressed
as thenumber of
such deaths per
1000 live birthsin
a specific
geographic area
or institution ina

given period of
time.
P u e r p e r
a l
S e p s i s :
Infection of the
genital tract
following

childbirth, still a
major cause of
maternaldeath
where is
undetected and
untreated.

A b o r
t i o n
s :
The termination
of pregnancy
before thefetus
reaches the stage
of viability (20
to24 weeks)

Miscarriage :
Spontaneous
abortion, lay term
usuallyreferring
specially to the
loss of thefetus
between the

fourth month
andviability.
P r e m a t u
r e
I n f a n t :
Infant born
before
completing week

37of gestation,
irrespective of
birthweight,
preterm infant.
L o w
B i r t h
W e i g h t :

Infant weighing
2500g or less at
birth
E c l a
m p s i
a :

Coma and
convulsive
seizures between
the 20
th

week of
pregnancy and
the end

of the first week

postpartum
Pregnancy
Induced
Hypertension:
Hypertensive
disorders of
pregnancyincludi

ng preeclampsia,
eclampsia,transie
nt hypertension.
Pelvic
Inflammatory
Disease :
Infection of
internal

reproductivestruc
tures and adjacent
tissuesusually
secondary to STD
infections.
Ectopic :
Out of normal
place

I n f e r
t i l i t
y
:
Decreased
capacity to
conceive

N e p h
r i t i
c
:
Related to the
kidney
C
t
s

y
i

s
t
:

Inflammation of
the bladder
usuallyoccurring
secondary to
ascending
urinary tract
infections

A m e n
o r r h e
a
:
Absence or
suppression of
menstruation.

Primary
Dysmenorrh
oea :
Painful
menstruation
beginning 2 to
6months after
menarche, related
toovulation

U t e r i n e
B l e e d i n g
) :
Falling, sinking,
or sliding of
theuterus from its
normal location
in the body.

M e t r o r
r h a g i a
:
Abnormal
bleeding from the
uterus,particularl
y when it occurs
at any timeother

than the
menstrual period.
M e n o r
r h a g i
a
:
Abnormally
profuse or

excessiveMenstru
al flow.
F o e t a l
D i s t r e s
s :
Evidence such as
a change in the
fetalheartbeat

pattern or activity
indicatingthat the
fetus is in
jeopardy.
Hypothermia :
The state in
which an
individuals body

temperature
reduced below
normal range.
Thrush :
Fungal infection
of the mouth or
throatcharacterize

d by the
formation of
whitepatches on a
red, moist,
inflamed
mucousmembran
e and is caused
by Candida
albicans

.
A p a
t h y
:
Lack of emotion
Dermatosis :

Any disease of
the skin in
whichinflammati
on is not
necessarily
a feature
S t o m a t
i t i s
:

An inflammation
of the mouth
Keratomalaci
a :
Softening of the
cornea seen in
early childhood

owingtodeficienci
es of vitamin A
H e m o p t
y s i s :
The
expectoration of
blood arising
from the oral

cavity,larynx,
trachea,
bronchi, lungs
characterized by
asudden attack of
coughing with
production of
saltysputum

containing frothy
bright red blood.
M o d e
s t y :
The quality of
being modest
Modest

: Having or
expressing a
humble.
Emphysem
a :
A chronic
pulmonary
disease marked

by an
abnormalincrease
in the size of air
spaces distal to
the
terminal bronchio
le with
destructive

changes in their
walls.

1.
MAGNITU
DE OF
MATERNA
L AND

CHILD
HEALTHP
ROBLEMS
DEFINITION
AND
MEANING
OF
MATERNAL

AND
CHILDHEAL
TH
Maternal and
Child Health
(MCH) refers to
a package of
comprehensive
health

careservices
which are
developed to
meet promotive,
preventive,
curative,
rehabilitativeheal
th care of
mothers and

children. It
includes the sub
areas of maternal
health,
childhealth,
family planning,
school health
and health
aspects of the

adolescents,han
dicapped children
and care for
children in
special settings.

DEFINITIO
N AND
CONCEPTS
OF

MATERNAL
HEALTH/R
EPRODUCTI
VE HEALTH
Maternal Health
is now referred as
Reproductive
Health

(RH).
According to
WHOit is defined
as a state of
complete
physical, mental
and social
wellbeing and not
merelythe

absence of
disease or
infirmity in all
matters relating
to the
reproductive
system andits
functions and
processes. It

implies that
people are able to
have a satisfying
and safesex life,
are informed
about to have
access to safe,
effective,
affordable and

acceptablemetho
ds of family
planning as well
as other methods
of their choice
for regulation
of fertility which
are not against
the law, are able

to have access to
appropriate
health
careservices that
will enable
women to go
safely through
pregnancy and
child birth

and provide
couples with the
best chance of
having healthy
babies. Reproduc
tive Health is
defined as
People have the
ability to

reproduce and
regulatetheir
fertility, women
are able to go
through
pregnancy and
child birth
safely,
theoutcome of

pregnancies is
successful in
terms of maternal
and infant
survival and
well being and
couples are able
to have sexual
relations free of

fear of
pregnancy and
of contracting
diseases.

OBJECTIVE
S OF
MATERNAL

AND CHILD
HEALTH
To reduce
maternal, infant
and childhood
mortality and
morbidity.

To reduce
perinatal and
neonatal
mortality and
morbidity.
Promoting
satisfying and
safe sex life.

Regulate fertility
so as to have
wanted and
healthy children
when desired.
Provide basic
maternal and

child Health Care

to all mothers and
children.
Promote and
protect health of
mothers.

To promote
reproductive
health.
To promote
physical and
psychological
development of
children and

adolescentswith
in the family.

GOALS OF
MATERNAL
AND CHILD
HEALTH
SERVICES

The main goal of

maternal and
child health
services is the
birth of a healthy
infant intothe
family and
prevention of
diseases in

mothers and
children. The
goals which
areincluded are
as follows:To ensure the
birth of a healthy

infant to every
expectant mother.
To provide
services to
promote the
healthy growth
and development
of children upto

the age of underfive- years.

To identify
health problems
in mother and
children at an
early stage and

initiate proper
treatment.
To prevent
malnutrition in
mothers and
children.

To promote
family planning
services to
improve the
health of mothers
and children.
To prevent
communicable

and noncommunicable
diseases in
mothers
andchildren.
To educate the
mothers on
improvement of

their own and

their childrens
health.

A.MATERNA
L HEALTH
PROBLEMS
The Maternal
Health Problems
are as follows:-I.

Nutritional
Problemsa)Maln
utrition b)Nutrit
ional AnemiaII.
Infection
Problems
a)
Reproductive
Tract Infections (

RTIs)/ Sexually
Transmitted
Infection
(STI) b)Infectio
n in
generalc)Puerpe
ral SepsisIII.
Disturbances and
MenstruationIV.

Mature
GravidasV.
Adolescent
GravidaVI.
Adolescent
Parents
ProblemsVII.
Unregulated

FertilityVIII.
AbortionsIX.
Complications of
DeliveriesX.
InfertilityXI.
Uterine Prolapse
XII. Cancer of
the Service

I.Nutritional
Problemsa)M
alnutrition
Malnutrition is a
very common
problem among
women who are
discriminated
andunderprivileg

ed. Pregnant and

nursing mothers
are especially
prone to the
effects
of malnutrition.
Malnutrition can
cause poor
resistance,

abortion, anemia,
miscarriage
or premature
delivery, low
birth weight baby
(<2.5kg),
eclampsia,
postpartum
hemorrhageetc.

These conditions
can cause fatal
effects on
mothers, unborn
and new born
babies.Malnutriti
on in women
needs to be
prevented and

treated by some
of the
directmeasures
such as nutrition
education,
modification and
improvement of
dietary
intake before,

during and after

pregnancy,
supplementation
of diet,
distribution of
iron andfolic
acids tablets,

subsidizing of
food items and
their fortification
and
enrichment.Other
measures which
can help prevent
mal-nutrition
include

prevention and
control
of infections by
improvement of
environmental
sanitation, safe
water supply,
food
and personal

hygiene,
immunization
treatment of
minor ailments,
regulation of
fertility
and practice of
small family

norm, and health

education.

b)Nutritional
Anemia
Anemia in
pregnancy is
defined as a
hemoglobin
concentration of

less than
11g%.Anemia is
a condition in
which
concentration of
hemoglobin in
the red blood cell
isreduced.
Hemoglobin is

essential for life.

It carries oxygen
to all parts of the
body for its
development and
day to day
function. It also
maintains the
immune system

which provides
resistance to
infection.
Therefore, an
anemia person
acquires infection
easily.Brain also
gets less oxygen
if a person is

anaemic.The
brain requires a
large quantity
of oxygen and
therefore the
child is anemic,
its brain
development
suffers. It is also

aserious public
health problem
in India.
Although it is
wide spread in
the country,
itespecially
affects woman in
reproductive age,

young children
and adolescent
girls.

Magnitude of
the Problem
More than half
of the pregnant
women during

pregnancy suffer
from
anemia.13%are
severely anemic.
Hemoglobin is
less than 7 gm/
deciliter.

1/5 of all
maternal deaths
are attributed to
anemia during
pregnancy.
More than half of
the adolescent
girls are anemic.

Anaemia
during
pregnancy
leads to
20% of all
maternal deaths.

3 times greater
risk of premature
delivery and
LBW babies.
9 times higher
risk of perinatal
mortality.

Higher risk of
irrecoverable
brain damage in
infants born to
severely
anaemicmothers.

Adverse
Effects

Maternal
depletion
Low Birth
Weight
Postpartum
Haemorrhage (
PPH)

Anaemia
Pregnancy
induced
Hypertension (
PIH)

Prevention of
Nutritional
Anaemia

Nutritional
Anaemia can be
easily prevented
by the following
ways:-

Promoting
consumption

of iron rich
food.

Regular
consumption of
iron rich food,
especially by
pregnant and
lactatingwomen,
adolescents girls

and boys and

children under 5
years of age.

Vitamin C
promotes
absorption of
iron. Vitamin C
rich foods are

lemon, orangeand
guava.

Tea and Coffee

inhibits
absorption of
iron in the
stomach. It is
advisable
toreduce intake

of tea and coffee

during
pregnancy. It
should otherwise
beavoided within
the one hour of
taking food or
iron tablets.

Promoting
growth of iron
rich at home will
increase the
availability of
iron in food,like
spinach, lemon,
amala, etc.

Promoting
consumption of
iron and folic
acid supplements.
Supplementary
iron inform of
tablets is the most
common strategy
for control of iron

deficiency
anemia.

II.Infection
Problems
a)

Reproductive
Tract

Infections
(RTIs)
/
Sexually
TransmittedI
nfection(STI)
RTIs include a
variety of

bacterial, viral
and protozoal
infections of the
lower andupper
reproductive
tract of both
sexes. RTIs pose
a threat to
womens lives

and well being

throughout the
world. A high
incidence of
infertility, tubal
pregnancy, and
poor reproductiv
e outcome is an
indirect

reflection of
high prevalence
of RTIs/ STIs
inIndia.
Vaginal
discharge is
amongst the
first 25%
reasons to

consult a
doctor. 40
%gynecological
OPD attendance
is because of
RTIs and 16 %
of
gynecologicalad
missions and due

to pelvic
inflammatory
disease (PID).

Causes of
Reproductive
Tract
Infection

Infections caused
by overgrowth of
organism
normally found
in the vaginal
tractare known as
endogenous
infection. These
infections are

associated with
inadequate perso
nal, sexual and
menstrual
hygienic
practices.
Sexually
Transmitted

Diseases (STDs)
are a specific
group of
communicabledi
seases that are
transmitted
through sexual
contact.

Infections which
are due to
inadequate
medical
procedures such
as unsafe
abortion,unsafe
delivery or
unhygienic IUD

insertion are
known as
iatrogenic
infections.

Signs and
Symptoms
Associated

with RTIsIn
women
Increased
discharge from
the vagina that
looks and smells
different from (

changein amount,
colour and smell)
Pain or burning
while urinating.
Painful or
painless sores,
blisters or warts

on or near the
genitals.
Pain on one or
both sides of
lower abdomen.

Irregular
menstrual
periods.
Pain or bleeding
during
intercourse.

Rash on the
entire body or
just on the palms
and soles.
Swelling on one
or both sides of
the groins.

In Men

Symptoms
usually appear
within 2-3 days
or a couple of
weeks or even
months
after having sex
with an infected
partner are:

Pus or discharge
from the penis.
Burning or pain
while urinating.
Painful or
painless sores,
blisters or warts

on or near the
penis.
Pain in one or
both the testicles.

Prevention of
RTIs and STI

Identify the
women with
RTIs/STI
Refer the
women to
medical officer
of PHC
promptly for

examination
andtreatment.
Identify sexual
partners and
ensure their
treatment.

Advice correct
use of condom
during every
sexual act.
Provide
counseling/health
education to
individuals,

family and
community.
Observe infection
prevention
measures
amongst the
health personnel.

A comprehensive
RTI/STI control
programme
requires three
levels of action.

Primary
Prevention

Avoiding
acquisition of
infection through
infected sexual
partners. Strategy
of
primary preventio
n includes
education and

counseling about
safe sex
practices, sexual
hygieneand
promotion of
condom use. Use
of condom
prevents

transmission of
RTIs/STIs.

Secondary
prevention
Secondary
prevention aims
at early detection
of signs and

symptoms and
early referralof
RTIs/STIs so that
spread of
infection to
others decreased,
in the peripheral
healthcaresetting
currently

treatment is
based on
syndromic
management.Co
unselling
andeducation to
motivate health
seeking
behaviour in

community by
reducing the
number of sexual
partners. Use of
most appropriate
antibiotics,
practicing proper
aspects
duringreproductiv

e interventions
and educations of
sex partners.

Tertiary
Prevention
Tertiary
Prevention
includes

controlling
complications of
RTIs.Strategies
for
tertiary preventio
n includes active
screening for
presence of
infection in high

risk groups
andappropriate
management.
Clinical
management of
septic abortion

Transport for
ectopic
pregnancy
Management for
infertility
Cervical cancer
screening

b)
Infection in
general
The women
during
pregnancy,
especially in
underdeveloped
areas and

developingcountr
ies are at risk of
contracting
infection.Many
women get
infected with
herpes simplex
virus,
cytomegalovirus

,
protozoonwhich
causes
toxoplasmosis, E
Coli causing
nephritis or
cystitis.
Infection
during pregnanc

y can cause
various harmful
effects e.g.
retardation of
fetal growth,
abortion,low
birth weight baby
and puerperal
sepsis.It is very

important that
women during
pregnancy need
to alert and
careful
regarding preven
tion and control
of infection.
They need to

seek antenatal
care right from
the beginning of
inception of
pregnancy so
that mothers get
proper antenatal
care and getwell
informed about

these infections
and participate in
prevention and
control of
theseinfections.

C)Puerperal
Sepsis
It is mainly due
to infection

during labour and

after delivery
because of lack
of
personalhygiene,
insanitary
conditions, septic
procedures, etc.
This may lead to

inflammation
of ovaries,
fallopian tubes,
endometrium,
cervix and
vagina. Many a
time
leucorrhoeamay
persist for years.

Some times
secondary
sterility may
follow after acute
or
chronicsalpingiti
es. Chronic
infections of
cervix may

predispose to
cancer of the
cervix. Itrequires
proper
preparations for
confinement by
the mother,
conduct of
deliveries

bytrained and
skillful dais,
midwives etc.and
availability of
equipments and
supplies etc.

III.
Disturbances

and
Menstruation
Amenorrhoea,
absence of
menstrual flow,
dysmenorrhoea,
painful
menstruation,ab
normal uterine

bleeding,
hypermenorrhoe
a/ menorrhagia,
excessive
bleeding(amount
and duration),
metrorrhagia,
bleeding between
menstrual

periods.Menstrua
tion is perceived
as a particular
problem for
women.
Intervention
programmesfor
various menstrual

problems are as
follows:-

Nursing
Intervention
for disturbed
menstruation
S.NNursi
ng

Diagnosi
sNursing
Interven
tion
1.Amenorr
h e a Ineffective
individualcoping
related to lack
of menstrual flow

Acknowledge
patients feeling

Provide
emotional
support

Refer to
counseling as
necessary

Explain
diagnostic
procedures

Provide
information,
privacy, or
consultation
asindicated
sexual

concern2.a.Dysm
enorrhoeaK n o w
ledge
d e f i c i t related
to the lack
of education
concerningdise
ase process
andtreatment

Provide
information on
orientation to
hospitalsetting,
disease process
procedures to be
performed,medic
ation and
treatment.

Prepare for
information,
question and
answer sessions
according to
patient needs

Teach procedure
to the patients

Obtain feedback

Be that certain
learning has
taken place

Develop a
trusting
relationship

Involve patient in
care b . P a i n
related to
b i o l o g i c a l agen
t

Assess the nature

of pain

Observe nonverbal cues

Encourage pain
reduction
technique as
appropriate

Explore best
method for

controlling
(medication, posi
tioning comfort
measure such as
backrub, or use
of heat or cold
etc.)

Monitor vital
signs

Provide quiet
environment ,
calm activities

Promote
wellness, discuss
other significant
wayswhich can
assist the

patient3 . M e n
orrhagia

Assess for
bleeding, pain,
vaginal
secretions
and psychosocial concern

Encourage the
woman to express
her feelings

Explain the
importance of
recording dates,
type of flow and
number of

sanitary pads or
tampons used

Teach the patient

pain- relieving
technique.

Explain the
importance of

sharing concerns
withher partner.

Certain
measures that
have to be
taken to
reduce this
problem are

asfollows:S.NReas
ons of
Anxiety
Nursing
Interven
tion
1.

Irritability,Lethar
gy,fatigue,depres
sion,headache,ver
tigo,backache,ach
e, paresthesia(bu
rning, tingling)
of hands and feet

Encourage
verbalization of
feelings

Acknowledge
existence of the
syndromeand its
symptoms

Encourage the
patient to keep a
menstrualsympt
om calendar to
document the
cycleand nature
of symptoms

Encourage the
patient to plan

activitiesduring
symptom free
part of her cycle

Administer
supplements of
vitamin
B6,calcium, and
magnesium as
prescribed

Encourage daily
exercises and
relaxation

Encourage self
help groups
and thereading
of self help
literature

Provide
emotional
support with
non judgemental
and caring
manner

Assist in
identifying

possible source
of anxiety

Assist in
identifying
coping
mechanism

Health
Teaching for
Menstruation
Knowledge of the
physiological
process.

Factors that may

alter the
menstrual cycle,
stress, fatigue,
exercise, acute or
chronicillness,
changes in
climate, or

working hours
and pregnancy.
Personal hygiene
Wear pads during
early period of
heavy flow.

Change tampons
frequently to
decrease risk of
toxic shock
syndrome ( TSS)
Consult
physicians if

tampons cause
discomfort.
Take daily
shower for
comfort (warm
baths may
relieve slight

pelvicdiscomfort
.)
Keep perineal
area clean and
dry, clean from
anterior to
posterior.

Cotton
underwear
preferred. Nylon
panty hose and
tight fitting
slacks
causeretention of
moisture and
should not be

used for extended

periods of time.
Feminine
hygiene
products such as
vaginal sprays
and
suppositories

maycontribute to
a feeling of
cleanliness.
Exercise
Exercise is not
contracted and

may help prevent

discomfort.
Modifies
exercises if
fatigue occurs.
Diet

Restrict salt
intake if fluid
retention is
present.
Consult physician
if fluid retention
persist after
menstruation.

Discomfort
For mild
discomfort take
aspirin or apply
warmth and rest.
For prolonged,
severe

discomfort,
consult
physician.
Sex during
menstruationTher
e is no
physiological
reason for a

woman to
abstain from
sexual activity
duringmenstruati
on. The uterine
contractions that
occur during
orgasm may
even ease

thediscomfort of
pelvic
congestion and
cramping.
During excessive
menstrual flow,
or physical
discomfort,

discourage the
sexual activities.

IV. Mature
Gravidas
The pregnant
woman over 35
years faces
unique problems.
The primigravida

in this
agecategory has
generally
decided to
postphone child
bearing until her
career is
wellestablished.
Although the

child may be
wanted and
anticipated, she
will often
havemuch
ambivalence and
concern about
how motherhood
will affect her

lifestyles
andhow it will
affect her
relationship with
the father of the
baby. She might
be the
singlewoman
deciding to have

a child on her
own, perhaps
even by artificial
insemination
or in vitro
fertilization. She
might be having
a child later in
her child bearing

years because of
remarriage or by
accident.It may
seem that these
women are the
best prepared
psychologically
for the demands
of pregnancy and

parenthood
because their
lives are stable.
This readiness
intensifies
their need for
nursing care.
They are heavily
invested in these

pregnancies
because of
theneed to have
the first, the
only, or the last
child or because
they have
decided to
carryand deliver

and unplanned
pregnancy
because it may
be their last
chance.
Whensomething
goes wrong or
threatens to go
wrong, there may

be guilt and
sorrow.Issues
particularly
important in
mature gravidas
are control and
past
coping behaviou
rs.Many women

have been
successful in
their careers by
manipulatingsitu
ations to their
advantages.
When faced
within a situation
in which they are

not incontrol and

must trust others,
severe anxiety
develops. Their
past coping
behaviourswill
not be effective,
and this will
intensify their

anxiety. They
feel unable to
take careof
themselves and
often have little
experience in
relying on others
during times of
need.The

educational
level of of the
client must be
considered
when
recommendingli
terature.
For woman
having first

pregnancy later
in life, fear
about the
infants health
andsurvival often
becomes the
dominant feeling.
This may be the
last egg in the

basket andthis is
very much
valued. As a
result, cesarean
birth is chosen
more often
byobstetricians,
and indicates an
overcautious

approach to birth
problems.

V. Adolescent
Gravida
The adolescent
mother and her
family create a
particularly
difficult problem.

The needscan be
so extensive
that care will
be fragmented
and ineffective
unless
andinterdisciplin
ary team
approach

coordinates the
school, social and
health care
services.The
scope of
adolescent
pregnancy is
enormous. The
mean age of

menarche is
around12 years.
Forty two percent
of girls and 64
percent of young
boys are sexually
active byage
18.A familys
reaction to teen

age pregnancy
varies
considerably. In
certain ethnic
andcultural
groups, teenage
parenting is
common. Indeed
the girls mother

may have beena

teenage parent
herself. In these
cases, the
situation is not a
crisis. In other
families,major
problems
result.Sex

education and
family planning
help to adolescent
gravida.

Sex Education
Adolescents lack
of knowledge
about their

bodies and
bodily changes.
Many
parentsfind it
difficult to talk
with their
children about
maturations,
birth control

and parenting.
Parents may not
understanding
that this
information is
vital and that it
must be given
early.Furstenbert
( 1980) found

that although 59
percent of
mothers
frequentlytalked
to their daughters
about sex, most
of the messages
were not get
mixed up

with boys and not

to do anything
she would be
sorry for later.
This is hardly the
informationteena
gers require. On
the other hand,
50 percent of

birth control
used
contraception
atleast
occasionally.

Family
Planning

The pregnancy
rate among
teenagers is so
high because
only one in three
sexuallyactive
teens always uses
contraceptives.
Only about half

of these use the

most
effectivemethod.
The most
common reasons
given by
teenagers for not
using

contraceptivesare
:

They dont feel

they will get
pregnant

They did not

anticipate having
intercourseWhile

the national
debate
continues over
where and by
whom sex
education progr
ammes should be
taught, research
is clear, we must

began early and

be
specific.Teenager
s are at risk not
only for
pregnancy but
also for STD
including HIV
infection.It is

unlikely that the

Government will
soon develop
policies to
encourage early
sexeducation
programmes
even though the
urgency of the

rates of HIV
infection and
of teenage
pregnancy
demands it.
As nurses, role is
two fold; nurse
must care for
adolescent

parents and
support
their parents and
teachers in
efforts to
communicate
about
responsible
sexual

behaviour before
pregnancy occurs
and after its
termination either
by abortion or
delivery.
Parentsand
teachers need
education also.

VI. Adolescent
Parents
Problems
The adolescent
father is often
neglected in
these situations.
Some families
are angryand

upset and will

ostracize him.
As other times
both families
pool their
financial, physic
al and emotional
resources to
support the

young parents as
they care for
their infant.
Some young men
are not involved
by their own
choice, but others
may
distancethemselv

es because they
assume that they
dont have a role
to play or they
are notneeded by
their partner for
support. They
may fear that
they will be

forced to marry
and provide
financial support
before they are
capable of doing
so. These young
men are inthe
same
developmental

stage as the
young women.
Teenagers
fathers have
many problems.
They are young,
are capable of
sexual
reproduction,

but not
consideredadults
, are cognitively
and
psychologically
immature
possess few legal
rights and areout
of life cycle

synchrony with
their
peers.Fathering a
child as an
adolescent is
associated with
reduced levels of
education
ingeneral. Lower

educational
levers limit career
choices and
earning potential.
Adequatewages
for male
employment
have been found
to be important

in determining
thesuccess of
early
marriage.Adolesc
ent parents are
rarely able to
support
themselves and
their children.

Optimally,the
family should be
involved early.
Detailed
arrangements
must be worked
out, andallowing
enough time
before delivery

makes the crisis

less
overwhelming.
Building
onsupplementing
family resources
and only
substituting for
families when

absolutelynecess
ary is belived to
be the most
effective way to
help adolescents
and their
infants.Women
who become
parents as

teenagers are less

likely to complete
their education
or to be
employed,
especially if they
are younger than
17 years.
Availability of

child
care,especially by
family members,
is crucial factor
in the mothers
returning to
school.Today, a
pregnant woman
has three

choices, to
abort, to have
the child place it
for foster care or
adoption, or to
have the child
and raise it.
Adolescents
parents have

thesame choices,
but may need to
guided through
the decision
making process.

Nursing
management

Nursing
diagnosis

Ineffective
individual
coping related to
developmental
level, situation in
which pregnancy
occurs.

Coping, family
potential for
growth related to
responses to
adolescent or
mature pregnant
woman.

Planning (
objectives)

Recognizes
potential for
growth in the
situation.

Chooses to obtain
pre- natal care.

Follows through
on referrals.

Seeks support for

expressed needs.

Recognizes fetal
needs for a
healthy start.

Nursing
interventions
Nurse must first
gain an
understanding of
the teenagers
situation when
she comesin for

the visit. She has

chosen to come
in, which reflects
a big decision for
her. Shemay be
afraid to tell her
parents, and the
dynamics
between them

will reveal
muchabout the
situation. She
and her family
may need a
variety of
assistance progr
ammes such as
public assistance,

or general social
service. Unless
you learnthis at
the First counter,
the young woman
may be lost to
follow up. Do
not waitfor her to
volunteer

information. It is
important to
engage her trust,
a difficult
talk because an
adolescent may
not trust easily
and may have
difficulty,

relating
toauthority
figures. The
adolescents fears
of
confidentiality.
A climate of
strictconfidential
ity is vital in all

nursing
situations, but is
crucial for
adolescents.
For these
reasons, care is
best given in a
setting that has
providers who

specialize
inadolescent
health care.
Respond to the
adolescents
needs rather than
to her behaviour.
For example

whenasked how
her mother feels
about the
pregnancy, a
teenager may
state
Fine.When
probed further,
she may get

angry and
respond, why
do you care
perhapsshe is
afraid to tell you
that she has not
hold her mother
or that her
mother

isinsisting that
she has an
abortion.
Respond to the
need, do not
react. For
examplestate,
lots of pregnant
girls of your age

have real
problems when
they tell
their parents or
are even afraid to
tell them. Let us
talk about that.
In this way, she
isgiven the

opportunity to
talk to a
provider who
shows care and
understanding.B
ecause she may
not want her
parents to know
where she is

going and is
concernedthat
you will call
them, a teenager
may not give
correct
information. She
may notable to
secure the

insurance
information on
her own. Ability
to pay or
provideinsuranc
e information
should also
become a
barrier to

provision of
care
of adolescents.
Identifies the
girls readiness
to use referrals.
Ask her to write
down sequence

of what has
planned together,
because tension
will prevent her
remembering
what todo.
Follow through
with telephone
contact is she

skips
appointments if
her familyis
aware of her
condition. If she
still doesnt tell
them early in the
pregnancy,
ask her for a way

to establish
contact. Keep
gently urging full
disclosure of the
family, because it
will become
evidence in a
very short time
that she is

pregnant. Help
her identify other
sources of
support in her
extended family
circle.
Peer support
groups in schools

for pregnant
adolescents or in
clinics are helpful
in preparing
teens to cope
with the
demands and
scarifies of
parenting.

Educational prog
rammes and
literature should
be geared to
teens. Providers
must like
workingwith the
teens and
understand their

unique problems
and responses.
The teens
father needs to be
involved as much
as possible. He
should be invited
to clinic visitsand
parenting

classes and
assisted to see
his role in
providing
physical
andemotional
support for his
partner and his
child.

Evaluation
The results of
comprehensive
care for a
teenage mother
would show
some of
thefollowing:-

Stated she
learned a great
deal about herself
and problem
solving.
Followed through
on referrals and

obtaining
assistance.
Involved father of
child in planning
and in care of
infant.

Followed
guidelines for
nutrition and self
care during the
pregnancy.
Attended school
and parenting
classes.

VII.
Unregulated
Fertility
Unregulated
fertility has been
recognized to
cause many
maternal health
hazards.

Theseinclude
abortions,
miscarriage,
premature
deliveries, low
birth weight
babies,antepartu
m haemorrhages
etc. All these

health hazards
are responsible
for highmaternal
and perinatal
mortality. It is
being
recognized to
regulate fertility
byintegrated and

comprehensive
approach in
family welfare
services which
includeeffective
measures related
to reproductive
health, child
health and family

planning.These
services should
be accessible and
acceptable to all
and utilized by all
the
women,children
and couples

throughout the
countries.

VIII.
Abortions
Twenty percent
of maternal
mortality is
directly related to
abortion related

causes.
Thenumber of
abortions is on
the increase
because of
unwanted
pregnancies.
MedicalTerminat
ion of Pregnancy

(MTP) has been

legalized under
the MTP Act of
1971,
under certain
conditions.By
and large
abortions are still
done by quacks

and unauthorized
persons in the
ruralareas. This
is mainly due to
lack of access to
safe abortion
clinics, nonavailability
of such clinics,

poor financial
resources to
reach to clinics
in urban areas,
lack
of information
about

the availability
of safe
abortions
clinics, lack of
privacy
andimpersonal
atmosphere in
the Government
run clinics and

reluctance of
unmarried
or widowed. It is
therefore very
important to
improve the
accessibility of
MTP services
in primary health

centers and create

awareness among
the people about
the availability
of such services.

IX.
Complications
of Deliveries

In India most of
the deliveries
take place at
home under
unhygienical
environment
andmostly by
untrained dais
lacking obstetric

skill. Often
various health
hazards results
insuch as
perineal tears,
cervical damage,
prolapse and
displacement of
uterus,

fetaldistress,
postpartum
hemorrhage etc.
Thus it is very
important to have
properly
trained,skilful
and qualified
health workers,

adequate
facilities and
well linked
referral
unitswhere
skillful and
efficient
emergency care
can be given to

save mother and

baby.

X. Infertility
Infertility is both
medical and
social problem
Even if the
fault/defect is in
the male partner,

usually it is the
woman who is
labeled as
Banjh or
Barren and is
sociallynot
treated properly
by the family
and the society.

Therefore this
problem is to
beconsidered
medically as well
as socially.
There is need to
have empathetic
attitudetowards
childlessness of

woman by
society.

XI. Uterine
Prolapse
Uterine prolapse
is the major
problem in
women of hilly
region. Women

working
atconstruction
sites, climbing
heights, or
digging and
ground or
climbing 2-3
storey withheavy
weights are

predisposed to
prolapse uterus.
Certain child
birth practices
such as pressing
hard on the
abdomen during
labour, pulling
the baby etc.lead

to prolapse of
theuterus,
especially when
the mother is
weak and
malnourished.
Uterine prolapse
maycause lot of
inconvenience to

mother and
predispose her to
infection. Hence
the needfor
trained and
skillful dais and
midwives,
improvement of
working

conditions
andeducation of
women.

XII. Cancer of
the Cervix
Cancer of the
cervix is very
common among
Indian women.

There are various

factorswhich
contribute to the
prevalence of
cancer of cervix.
These are early
marriage
andearly
pregnancy,

multiple child
birth, poor
hygiene by the
male partner,
multiple partners
, and repeated
infections. Most
of these factors
are pertaining to

socioculturalaspe
cts of a
community and
families are
imply involving
attitudinal
change in
these practices to
prevent the

occurrence of
cancer of the
cervix.

B. CHILD
HEALTH
PROBLEMS
I. Nutritional
deficiency
Problems

a) Malnutritionb)
Vitamin
Deficiencyc) Iron
Deficiencyd)
Low Birth
Weight
III.Infectious
Diseases

a)Tuberculosis
b)Diphtheriac)
Pertussis
(Whooping
Cough)d)Tetan
use)Poliomyeli
tisf ) M e a s l e s g)
Acute
Respiratory

Infection
(ARI)h)Diarrho
eal Diseases
IV.Problems of
Neonates
a)Hyper
bilirubinemia b)
Hypothermiac)
Neo-natal

tetanusd)Birth
asphyxia
e)
Oral
thrushf ) s e p s i s g
)The infected
New Born

I. Nutritional
deficiency

Problemsa)M
alnutrition
The primary
cause of
malnutrition is
inadequate and
faulty diet. Apart
from poverty
andother socio

economic
factors,
environmental
factors also play
an important role
inaggravating
the dietary
deficiency
diseases. These

precipitating
factors are
thewidespread
chronic
infections
among the poor
living under
conditions of
poor environmen

tal sanitation and

personal
hygiene.Malnutrit
ion continues to
be a major health
problem in the
world today,
particularly
inchildren

younger than 5
years of age.
Lack of food;
however is not
always the
primarycause for
malnutrition. In
many developing
and

underdeveloped
nations, diarrhea
is amajor factor.
Additional
factors are bottle
feeding (in poor
sanitary
conditions),inade
quate knowledge

of proper child
care practices,
parental
illiteracy,
economic
and political
factors, and
simply the lack of

adequate food for

children.

Levels of
Malnutrition
India has among
the highest
levels of child
malnutrition in
the world, and

the persistence of
the problem has
led to the
formulator of the
National
Nutrition policy
bythe
government of
India. UNICEF

reports auch
programmes
through strategies
promoteBF and
to timely
introduction of
complementary
foods,
encouraging

clean
environmentwith
portable water,
and tackling
diarrhoeal and
other infections.

Reasons for
the problems
of

Malnutrition
in India
Food availability
and Related
Problems

Low per capita

food availability

Low purchasing
capacity of the
masses

Mal distribution
of the available
food

Limited choice of
food articles.

Poverty and
Malnutrition

Ramification of
poverty

Low income of
the masses

Poverty
malnutrition
interaction
Population
Problem and
Malnutrition

Population
explosion

Effects on food
availability

Effects of
uncontrolled
fertility on
nutrition.
Social Factors
Affecting

Nutritional
Status

Customs,
superstitions and
taboos.

Diet during
illness

Caste and false

social status.

Food tastes and

faulty cooking
methods.

Food
combinations.

Influence of
industrialization
and urbanization
and
modernization.

Ignorance and
lack of education.

Alcohol and
malnutrition.

Protein
Energy
Malnutrition
Protein Energy
Malnutrition is
defined as a
range of

pathological
conditions
arisingfrom
coincident lack
of varying
proportions of
protein and
calorie,
occurring

mostfrequently in
infants and young
children and
often associated
with infection.
-WHO 1973
PEM has been
identified since
long as a major

nutritional
problem in
India.Insufficien
cy of food the so
called food
gap appears to
be the chief
cause of
PEM,which is a

major health
problem
particularly in the
first years of life.
Various studies
ondietary intake
reveal that the
gap intake
among children

on habitual
cereal
pulse based diet
is primarily due
to inadequate
intake of such
diets and not the
quality
of protein.

Severe form of
malnutrition
(PEM) leads to
two clinical
forms of
disorders.They
are as follows:

Kwashiorkor

Kwashiorkor is
the condition of
deficiency of
protein with an
adequate supply
of calories. A
diet consisting
mainly of starch
grains or tubers

provides
adequate calories
in the form of
carbohydrates
but an
inadequate
amount of high
quality proteins.
Thechild with

kwashiorkor has
thin, wasted
extremities and a
prominent
abdomen
fromedema
(ascites). The
edema often
masks the severe

muscular atrophy,
making the
childappear less
debilitated than
he or she actually
is. The skin is
scaly and dry and
has areasof
depigmentation.D

iarrhoea
commonly
occurs from
lowered
resistance to
infection and
produceselectrol
yte imbalance.
Protein

deficiency
increases the
childs
susceptibility
toinfection,
which eventually
results in death.

Marasmus

Marasmus results
from general
malnutrition of
both calories and
protein. It is
commonoccurren
ce in
underdeveloped
countries during

the times of the

drought,
especially
incultures where
adults eat first,
the remaining
food is often in
sufficient in
quality

andquantity for
the
children.Marasm
us is usually a
syndrome of
physical and
emotional
deprivation and
is notconfined

to geographic
areas where
food supplies
are inadequate.
Marasmus
ischaracterized
by gradual
wasting and
atrophy of body

tissues,
especially
of subcutaneous
fat. The child
appears to be
very old, with
flabby and
wrinkled skin.
Thechild is

fretful, apathetic,
withdrawn and so
lethargic

Causes of
Protein
Energy
Malnutritiona

)Nutritional
Factors
Poor caring
practices include
Not feeding the
sick children.

Not providing
the adequate
complementary
feeding.
Not supporting
mothers to breastfeed adequately.

Non breastfed.
Late weaning.
Inadequate
supplementation.
Failure to feed
during illness.

Failure to
increase to
caloric intake
immediately after
the illness.

b)Non
Nutritional
Factors

Due to poverty,
mother is not able
to provide
sufficient food to
the child resulting
inunder nutrition.
Nonimmunization

Improper growth
monitoring.
Poor weight gain
during
adolescence
Poor
environmental

and personal
hygiene
Illiteracy
Large family
False beliefs

Failure to utilize
Health/Hospital
care.
Low agricultural
inputs,
marketing,
distribution of
food and income.

Poor and
inadequate water
and sanitation
facilities.
Political
Problems

Inadequate
resources include
money, material
and manpower
refers to the
poor quality,
expensive and
non convenience.

Lack of health
care services and
information
regarding
maternal and
child
care practices on
basis of
inadequate time

and resources for

taking care of
healthdiet,
emotional and
psychological
needs of women
and children.

Poor caring
practices include
Poor antenatal
care.
Food taboos
during and after
pregnancy.

Inadequate
management of
sick and
malnourished.
Infestation like
ascariasis
particularly

giardiasis may
lead to anorexia.

Signs and
Symptoms of
different types
of PEM
Kwashiorkor

Oedema of the
face and lower
limbs
Failure to thrive
Anorexia
Diarrhoea

Apathy
Dermatosis (
hypo and hyperpigmentation)
Sparce
Soft and thin
hair

Angular
stomatitis
Cheilosis
Anemia

Marasmus

Failure to thrive
Irritability
Fretfulness and
apathy are
common

Diarrhoea is
frequent
Many are hungry
but some may be
anorexic
The child is
shrunk and there

is little or no
subcutaneous fat.
There is often
dehydration
Temperature is
subnormal

Watery diarrhea
and acid stools
may be present.
Muscles are weak
and atrophic
Limbs appear as
skin and bones

Marasmic
Kwashiorkor
These children
exhibit a mixture
of some of the
features of both

marasmus
andkwashiorkor.

Management
of PEM
Therapeutic
Management

Adequate
nutritious diet
either by
breastfeeding or a
proper weaning
diet.
Five grams of
protein/ kg body

weight/day
should be given
for the existing
weight.
Rehydration with
an oral
rehydration
solution that also

replaces
electrolytes.
Treatment of
infections.
Medications such
as antibiotics and
antidiarrheals.

Health education
Fats: Forty
percent of total
calories can be
from fat which
can be tolerated
bychildren.
Saturated fats

such as butter,
milk and coconut
oil are preferred
becauseunsaturat
ed fatty acids
worsen diarrhea.
Energy: It is
important that

there should be
enough calories
in the diet;
otherwise protein
s will be utilized
for energy
purposes and not
for building the
tissues.

Vitamin A should
be supplied
immediately.
Anemia: Folic
acid should be
given

Nursing Care
Management
Provision of
essential
physiologic
needs, such as
protection from
infection,adequa

te hydration,
skin care and
restoration of
physiologic
integrity
becausechildren
usually weak and
withdrawn, they

depend on others
for feeding.
Oral rehydration
with an approved
oral rehydration
solution is
commonly used
incases of PEM

where diarrhea
and infection are
not immediately
life threatening.
Health
education
concerning the
importance of

proper nutrition,
whether breastfe
eding or bottle
feeding, when
being weaned to
semisolid foods.
Children with
marasmus may

suffer from
emotional
starvation as
well; care
should be
consistent with
care of the child
with failure to
thrive.

b)

Vitamin
DeficiencyVita
min A
deficiency
Vitamin A
deficiency is a
major nutritional
problem affecting

young children
leading
to blindness.In
India about 5 7
percent children
suffer annually
from eye
damage caused
byvitamin A

Deficiency,
Recent evidence
suggests that
mild vitamin A
deficiency
probably
increases
morbidity and
mortality in

children,
highlighting the
public
healthimportance
of this
disorder.Surveys
show, that 1-5
percent of
children have

clinical signs of
vitamin A
deficiency.The
prevalence rates
are higher in
school age
children than in
younger age
groups, butsevere

forms of the
deficiency
resulting in
blindness are
confined to
children below
3years.The
causes of severe
form of vitamin

A deficiency like
Xerophthalmia
arises when
thediet contains
practically no
whole milk and
butter and very
limited amounts
of

freshvegetables
and fruit so
lacks both
retinol and
carotenes.Xero
phthalmia
andkeratomalacia
both occur in the
first year of life

amongst
artificially fed
infants but
rareamongst the
breast fed. If the
mothers diet
during pregnancy
is low in vitamin
A, thechild is

born with low

stores of
vitamin A.
Protein energy
Malnutrition
further aggravate
s the partial
deficiency
because

absorption and
plasma transport
of vitamin Aare
impaired.Diarrho
ea is known to be
a precipitating
factor in
keratomalacia.
Themajor factors

contributing to
low availability
of vitamin A are
lack of awareness
of theimportance
of consuming
vitamin A rich
food and
poverty leading

to
limitedaccessibil
ity to vitamin A
rich food.

The Clinical
Forms of the
Deficiency will
include:-

Vitamin A
Deficiency: Vitamin A
deficiency is
seen more
commonly
inyounger
children i.e.
between 6

months and 3
years. Vitamin A
is indispensable
for normal
functioning of the
eyes. It helps in
the production of
retinal pigments
whichare

required for
vision in dim
light.

Conjunctival
Xerosis:
-.
The conjunctiva
becomes dry,

appears muddy
andwrinkled due
to failure to shed
the epithelial
cells and
consequent
keratinisation.Th
e pigmentation
gives the

conjunctiva a
peculiar smoky
appearance.
Thissymptom in
children under 5
years is more
likely to be due to
dietary
deficiency.

Night
blindness:
This is the first
sign of
Xerophthalmia.
The child is not
ableto see in

darkness in a
dark room or
when it gets dark
in the late
evening. This
isdue to lack of
retinal pigments.

Bitots spots:

Although Bitots
spots differ
somewhat in
size, location
andshape, they
have similar
appearance.
They are

accumulations
of fomy
cheesymaterial
on the
conjunctiva on
either side of the
cornea, often in
association
withother signs

of
Xerophthalmia,
such as
blindness. In
children under 5
years of agethey
are usually due to
vitamin A
deficiency.

Corneal
Xerosis/
ulceration: The cornea
becomes dry
(xerosis). If
thedisease is not
treated, the

xerosis can
progress within
hours to an ulcer
of thecornea.
Corneal Xerosis
may progress
suddenly and
rapidly to
keratomalacia.

Keratomalaci
a:
In this softening
and dissolution
of the cornea
occurs. If
the process is not

stopped by
treatment,
perforation of the
corneal leads to
prolapsed of the
iris, extrusion of
the lens and
infection of the
whole eyeball

which
almostinvariably
occurs. The
chance of saving
any useful vision
are slight.
Heating resultsin
scarring of the
whole eye and

frequently in total
blindness.

Xerophthalmi
a fundus:
In school
children or
young adults

with
prolongedvitamin
A deficiency
ophthalmoscopic
examination may
show lesions
appearing
asspots, either
white or yellow

scattered along
the sides of the
blood vessels.
Thespots may
fuse and the
lesions are most
numerous on the
periphery of the
fundus( boral

portion) and
never appear on
the macula (the
yellow spot on
the retina.

Corneal scars:
-

These are white,

opaque patches
on the cornea as
a result
of healing of an
older ulcer.
Vision may be
affected
seriously,

depending on the
size of the scars.

Management
of Vitamin A
Deficiency
Immediately on
diagnosis,
water soluble

1, 00,000 IU of
vitamin
Aintramuscular
ly can be given
for corneal
xerosis, ulcer,
keratomalcia,xe
rophthalmia,

severe infection
and malnutrition.
Immediately on
diagnosis for less
severe forms like
night blindness,
conjunctivalxeros
is, Bitots spot,

oil solutions as
palmitate 2,
00,000 IU can be
given orally.
On second day
oil solution of 2,
00, 000 IU orally
should be given

prior to
thedischarge
from the hospital.

Preventive
Measures
Nutrition and
health education

should be given
to the mothers.
Pregnant and
lactating mothers
should be
encouraged to
consume dark
greenleafy

vegetables and
yellow or orange
fruits so that
there is sufficient
storage invitamin
A in the liver of
new born.

Mothers should
be motivated to
feed their
children as
vitamin A
present in
themilk is
adequate for 3 to

6 months of
infants life.
The weaning
diet should be
consist of dark
green leafy
vegetables,
yellow or orange

fruits, whole
milk, butter, fish
and egg.
National
Vitamin A
supplementation
programme is a
more effective

alternateapproach
.
Other measures:Medical
paramedical
personnel
should be

trained to detect
and
treatxerophthalm
ia.
They should
know the
importance of
giving vitamin A

oily solution once

in 6months at the
door steps of the
beneficiaries as
community
approach but not
athospital as
clinical approach.

They should
monitor
periodically
National
Vitamin A
prophylaxis pro
gramme.

Medical and
paramedical
personnel should
be given nutrition
education.
To prevent
vitamin A
deficiency

intake of green
leafy vegetables,
yellowfruits its
and vegetables
like papaya,
mango, pumpkin
and carrots
should
be promoted for

long term
measures kitchen
garden should be
encouraged.

Vitamin D
Deficiency
Deficiency of
vitamin D causes
rickets in young

children in the
age group of 6
monthsto 2 years.
It reduces
calcifications of
bones which
affects growth of
bones and
causedeformity

of bones such as
curved legs,
pigeon chest,
rickety rosary,
deformed
pelvis.There is
delayed
teething,
standing and

walking. It is no
more a serious
problem because
of improvement
in child health
care services,
socio-cultural
practices, plenty
of available

sunshine.Rickets
is preventable
by simple
methods like
exposure of
children to
sunshineregularl
y and
administration

of vitamin D as
prophylaxis
periodically. It
requireseducatio
n of mothers and
family members
about the
importance of
exposure of

childrento
sunshine
regularly and to
give food rich in
vitamin D such
as butter, cheese,
eggyolk, liver,
fortified food
such as milk,

vanaspati oil etc.

Fish liver oil is
very goodsource
of vitamin D and
is available in
the form of
capsule which
can be given
under the

direction of
medical
officer.Excessive
intake of
vitamin D is
harmful. It may
cause loss of
appetite,
nausea,vomiting

, excessive
thirst and
drowsiness.
There may be
renal failure,
cardiacarrythemi
as and
unconsciousness.
All this is due to

increased level
of calcium in
the blood due to
increased
absorption of
calcium. It is very
important to
recognize the
signsof rickets

and refer the

child to PHC/
Hospital etc. for
therapeutic
treatment as early
as possible. The
mothers and
family members
need to be

educated about
the
observationsof
signs and
reporting in the
health center to
treat and vitamin
d deficiency in
children.

c)Iron
Deficiency
The iron
deficiency
causes
nutritional
anaemia in
children. About
50 percent

of children have
anaemia. It is
due to
malnutrition. It
usually leads to
various
others problems
such as general
weakness

affecting work
performance,
reduced
immunity
andresistance to
infections
resulting in
increased
morbidity and

mortality. It
affects physical
and
psychological
behaviour of the
children. There
is decrease in
theconcentration
of hemoglobin

and it is lower
than the normal
cut off point set
up byWHO,
which is 11 g/dl
in children 6
months to 6
years. Anaemia
is aggravated

byworm
infestation and
malarial
parasites. It may
also be caused
because of
theseinfections.
Another factor
which causes

anaemia is folic
acid (folate)
deficiency.Anae
mia in children
can be prevented
by preventing
and controlling
of anaemia
in pregnant and

nursing mothers
by improvement
in diet and
prophylactic
treatment by
iron folic acid,
and nursing
mothers by
improvement of

diet of children
emphasizingon
breast feeding,
proper weaning
and
supplementation
etc, iron folic
acid
drops/tablets as

prophylaxis,
prevention and
treatment of
worm infestation
and
malaria.Fortified
salt with iron has
been tried out by
National Institute

of Nutrition to
controlanemia in
regions with high
prevalence of
anaemia and is
accepted by the
governmentas a
public health
approach to

prevent
anaemia.Commer
cially Iron
fortified salt is
available in the
market. The
mothers and
familymembers
and community

people need to be
educated by
health workers
about all
these preventive
measures.Monito
ring of growth
and development
and anaemia is

very important
to make
anassessment of
malnutrition and
anaemia and
accordingly take
corrective
measures.

Role of Nurse

The nurse and the

team of health
workers can play
a very important
role in
preventionand
control of
nutritional
problems in

children. She
needs to:Encourage
mothers and
family members
to monitor
growth and
development

of their children
and to bring
them to health
centers for
regular check up
and
recordweight,
height etc.

Ensure 100%
coverage of
administration of
vitamin A mega
doses to children.
Help and guide
health workers
and mothers

detect early cases

of malnutrition
andother
nutritional
deficiencies such
as vitamin A,
iron and vitamin
D and refer
themto health

centres as the
need to be.
Guide and
supervise health
workers to
participate in
nutrition
programmes

likeIntegrated
Child
Development
Scheme,
Nutritional
Anaemia
prophylaxis pro
gramme,
midday meal

programme and
other nutrition
supplementary
programmes.

d)Low Birth
Weight
It is major
nutritional public
health problem

in many
developing
countries. Low
birthweight is a
major public
health problem
in many
developing
countries. About

30 percent of
babies born in
India are low
birth weight as
compared to 4
percent in
somedeveloped
countries. In
countries when

the proportion of
low birth weight
is high
themajority are
suffering from
fetal growth
retardation.In
countries where
the proportion of

low birth weight

infants is low,
most of them
are preterm.
Although we
dont know all
the causes of
low birth

weight,
maternalmalnutri
tion and anaemia
appear to be
significant risk
factors in its
occurrence.
Amongthe other
causes are of low

birth weight are

hard physical
labour during
pregnancy
andillnesses
especially are
due to infections.
Short maternal
stature, very

young age,
high parity,
smoking, class
birth intervals
are all associated
factors. All these
factors
areinterrelated.Si
nce the problem

is multifactorial,
there is no
universal
solution.

Classification
of Low Birth
Weight

Pre- term
babies
These are
babies born too
early before 37
weeks of
gestation (less
than

259days).Approx
imately, 2/3
rd

of all babies of
low birth weight
in developed
countries
areestimated to
be pre-term.

Small for date

( SFD) Babies
Any infant
whose birth
weight is below
the 10
th

percentile for the

gestational age

iscalled small for

date.SFD babies
have a high risk
of dying not only
during the
neonatal period
but during their
infancy. Most of
them become

victims of PEM
and
infection.Thus
they contribute
significantly to
poor child
survival and
raise the rates of
infantsand

perinatal
mortality and
pose immediate
and long term
problems such as
mentalretardation
.

Causes

Maternal
malnutrition and
anaemia
Physical labour
during pregnancy
Infection
Short stature

Very young age

High parity
Smoking
Close birth
intervals

Epidemiology
The
epidemiology is
not well
understood. In 30
to 505 of cases
the cause is
unknown.In the
developing

countries
adverse pre and
postnatal
development of
the child
isassociated with
3 interrelated
conditions.

Maternal
Malnutrition
Infections
Unregulated
fertilityThe
above conditions
are due to poor

socio economic
conditions and
environmentalco
nditions,
including scarcity
of health and
social welfare
services.Besides
the above several

other risk factors

during pregnancy
have been
identified.These
include:Hard physical
labour

Smoking
Poor maternal
weight gain (less
than 8 kg.)
Maternal height
less than 145cm.

Maternal weight
below 40 kg.
Young maternal
age below 20.
Shorter birth
intervals less than
2 years.

Lack of antenatal
care
Medical
conditions such
as anemia, high
blood pressure
and toxaemias.

Management
of Low Birth
Weight
Newborn
One third of all
newborns are
low birth weight.
These new borns
are at a higher

risk hypothermia
, infections and
death. It is
possible to save
most of these
babies
withsimple
intervention.

Provide warmth
Exclusive breast
feeding
Prevent
infections
Teach mother to
recognize danger

signs seeking
help.

Refusal of feeds

Increased
drowsiness

Difficult
breathing

Apnoea

Cold to touch

Yellow staining
of skin

Convulsions

Prevention of
Low Birth
Weight Babies

Increasing
Food Intake

Even during the

last trimester,
small dietary
improvement
can result in
asignificant
improvement in

the weight of the

infant. It
includes wide
range
of activities.

Supplementary
feeding

Distribution of
iron and folic
acids tablets.

Fortification and
enrichment of
foods.

Controlling
Infection
Maternal
infection should
be diagnosed and
treated.Malaria,
filiria infections,
rubellaand
syphilitic

infection should
be prevented.

Early
Detection of
Conditions or
Problems and

treatment
forDisorders

Family planning

Prenatal advice

Improvement in
socio- economic
conditions and

environmental
conditions.

Availability of
health and social
services.

II. Infectious
Diseasesa)Tu
berculosis

It is a
communicable
disease suffered
by all ages. It is a
problem in
community. It is
aninfectious
disease caused
by

mycobacterium
tuberculosis.
The major
source
of infection is
infected sputum
of persons
having
tuberculosis who

are either not

beingtreated or
not being fully
treated. They are
source of
infection to
environment
and people
around them. The

other source of
infection is
infected milk of
affected
animalse.g.
cattles i.e. bovine
source. In India.
This source of
infection is

uncommon
becauseof the
practice of
boiling of milk
before use. The
tubercle bacilli
primarily affects
lungsand cause
pulmonary

tuberculosis, but
can also affect
other organs like
intestines,menin
ges, bones and
joints, hymph
glands
etc.Tuberculosis
affects all age

group. The
incidence of
infections
increases sharply
frominfancy to
adolescence. One
percent of
children in the
age group under

five are
infectedwith
tubercle bacilli as
evidenced by
tuberculin test.
The incidence of
infection is
morein male
children than in

female children.
The risk of
developing
tuberculosis
disease ishigh in
preschool years.
The child is not
born with
immunity. It is

acquired as a
resultof natural
infection or BCG
vaccination.
Children who are
malnourished and
living indark and
dying and over
crowed places

have poor
resistance and
have
increasedchances
of developing
tuberculosis.The
disease is
transmitted
mainly by

infected droplets
exchaled out by
sputum
positive patients
especially by
coughing,
sneezing
etc.Tuberculosis
is not transmitted

by simplecoming
in contact with
articles used by
infected patients.
The infection
also can enter by
ingestion of
unboiled milk
and may initiate

intestinal
tuberculosis.The
incubation
period of
tuberculosis
disease ranges
from few weeks
to months
or years

depending upon
the virulence and
dose of the
tuberculosis
bacilli. The
disease
ischaracterized
by:

Toxemic
symptoms such
as low grade
fever especially
in the evening,
loss of weight,
lethargy.

Localized
symptoms
depending upon
the site of
infection and
symptoms can
be persient
coughing with or
without sputum,

hemoptysis if the
infection is in
thelungs, pain in
chest and
dyspnoea if the
infection is of
pleura,
hoarseness of
voice if the

infection is in
larynx, diarrhea if
infection is of
intestine. The
most common
siteof infection is
lungs.
The pulmonary
tuberculosis

diagnosis is
conformed by Xray examination,
examinationof
sputum and
tuberculin test.

Magnitude of
the problem

Not a single
country
succeeded in
reaching a point
of control i.e.
less than 1
percenttuberculin
positive among
children of age

group 0 to 14. In
the world there
are about:15 million cases
of infectious
tuberculosis at
present

2-3 million cases

are added every
year
1-2 million
people die every
year.

The problem is
acute in
developing
countries. More
than of total
cases
of tuberculosis
and more than
of total

tuberculosis
deaths occur in
developingcount
ries.

Prevalence of
infections: - It is
evinced by
tuberculin that
testing on an

average50
percent of
population are
infected at any
time.

Mortality: - One
million each year.

Morbidity
survey:-Prevalence rate
of active cases,
1.8 percent
population out
0.4 percent.Prevalence rate
in towns, cities

and villages are

same.Prevalence rate
showed increase
with age.

Prevention
and Control of
Tuberculosis

Tuberculosis is
preventable by
health promotion
and specific
protection of
childrenunder
five. These
measures
include:-

Improving
general health
and resistance of
children by
improving living
conditionsi.e.
clean, well
ventilated and

open houses,
good nutrition,
healthful habits,
goodenvironment
al sanitation etc.
Specific
protection by
BCG.

Immunization of
children as
discussed earlier,
health education
of parents and
other family
members
regarding health

promotion and
specific
protection of
children andother
members in the
family.
In order to
control further

spread of
infection it is
very important to
find out
cases,conform
diagnosis and
initiate and
complete the
course of

treatment not
only to break the
chain of
transmission of
disease but also
to cure the
disease.

It is therefore
necessary for all
health workers to
help identify
tuberculosis cases
onthe basis of
presumptive
clinical
symptoms.

Anyone having
low grade
temperature
especially in the
evening, loss of
weight,general
debility, cough or
without sputum

for a month or
more should be
referred
toPHC/CHC/Che
st clinic.
They should
follow up cases
to continue

regular
treatment when
put on antituberculosis
treatment.
They should also
educate the
parents, family

members and
community at
largeregarding
recognition of
signs and
symptoms and
availing of
medical
facilitiesavailabl

e for early
diagnosis and
treatment,
regular and
uninterrupted
treatmentwhich
is prescribed.

Health
supervisor/
Community
health nurse
must supervise
and guide
healthworkers in
carrying these
responsibilities.

b)Diphtheria
Diphtheria is
very serious
disease because
if it is not treated
immediately it
leads tohigh
mortality. It is
caused by

corynebacterium
diphtheriae.The
source of
infection aremild
and missed cases
and
convalescent
and healthy
carriers. The

persons
remainineffective
usually for two
weeks to four
weeks if no
treatment is
given. The rare
cases become
chronic carriers.

They may remain

ineffective for 6
months or
more.Diphtheria
is transmitted by
direct droplet and
direct airborne. It
is also
transmitted

byindirectly by
inhaling
contamitted dust
particles.
Transmission can
also be
transmitted by
using contamitted
articles used by

the patient but

only for a short
period.The
incidences of
diphtheria are
highest in the age
group of 1-3
years. The
incidencesare

very low in
infants below six
months of age
because of
immunity
obtained
frommother. By
3-5 years of age,
most of the

children (7099%) acquire

active
immunity becaus
e of in apparent
infection.
Therefore
incidences are
low from 3-5

years of ageand
thereafter very
rare. The
incidence of
diphtheria occurs
throughout the
year butmore
during winter
season. The

average
incubation
period of disease
is 3-4 days;
itranges from 2-6
days.

Magnitude of
the problem

Diphtheria is a
worldwide
problem in most
developed
countries owing
to
routinechildren
vaccination. In
developed

countries like
England and
Wales there were
only 5cases of
diphtheria in
1980 as against
46,281 cases,
seen among
nonimmunisedch

ildren. In India, it
is an endemic
disease. The
available data
indicate a
declining trendof
diphtheria in the
ID Hospitals,
Mubai, Chenni,

Delhi and
Bangalore. This
may bedue to
increasing
coverage of the
child population
by immunization.
Fatality rate on
anaverage is

about 10 percent
which has
changed little in
the past 50 years
in untreatedcases
and about 5
percent in treated
cases.

Prevention
and Control
Diphtheria is
preventable by
specific
protection by
immunization of

all childrenwith
diphtheria toxoid.
The children
should be
immunized as
early as possible
so as to protect
them beforethey

lose their natural

immunity.
The
immunization of
diphtheria is
done by
combined or
mixed vaccines

whichinclude
diphtheria,
pertusis and
tetanus vaccine
(DPT).
It is very
important that
health workers

put in all the

efforts to
immunize all
thechildren. They
educate parents
and family
members about
the same.

In order to
control the
infection it is
necessary to
recognize the
cases clinically
andrefer them
immediately to
CHC/ hospital

without loss of
time to be able to
starttreatment
immediately.
The treatment is
started without
waiting for
laboratory

conformation.
The
usualtreatment is
the
administration of
antidiphtheric
serum. The
dosage varies
from20000 to

100,000 units
depending upon
the severity of
disease.
Sensitivity is
done before
administering. in
addition to
antitoxin,

antibiotics either
procain penicillin
or erythromycin
are also given for
10 to 12 days.
These children
are must be
isolated from

other children in
the family till
they
aretransferred to
CHC/ hospital.
These affected
children should
be kept

under surveillanc
e.
If they have
already been
immunized
completely
within two years
time, no

further immuniza
tion is necessary.
Only throat swab
culture should be
taken for
whichnecessary
action should be
taken.

If complete
immunization
was done within
more than two
years time, only
a booster dose of
diphtheria toxoid
need to be given.
A throat swab

for culture
alsoneeds to be
taken and
necessary action
must be taken for
the same.
Those children
who are not

immunized are
put on
prophylactic
treatment and
are placed under
medical
supervision.
They must be
referred to

CHC/PHC.
Repeatedculture
of throat swabs
for these children
is necessary to
conform their
infectivestatus.

Proper
disinfection of
clothes, formities
and sputum
should be done.
The community
health nurses and
health

supervisors must
see that these
actions
are properly
implemented by
health workers
and family
members. They
need toeducated,

trained and
supervised to
ensure effective
prevention and
control
of diphtheria in
children.

c)Pertussis
(Whooping
Cough)
Whooping
cough is an
acute infectious
disease causing
complications
and

highmortality in
many parts of the
world. It is
caused by
Bordetella
Pertussis.The
source
of infection is
infected human

being. These
may be typical,
mild or missed
cases.
Theinfection is
present in
nasopharyngeal
and bronchial
secretions. The

disease is
mostcommunica
ble during the
later part of
incubation
period and
inflammatory
stage(catarrhal
stage). The

period of
infectivity
usually extends
from one week
after exposure to
infection to about
3 weeks after the
onset of typical
whooping

cough.The
infection is
transmitted
directly by
droplets of
infected persons.
It can also
betransmitted by
use of freshly

contamitted
articles. The
period of
incubation
usuallyranges
from 7 14 days,
but in any case
not more than 21
days.The

prevalence of
disease is in all
the countries. But
the incidence of
whooping
coughis on the
decline. Disease
is more common
in tempo rate

climate and
during winter
andspring
seasons. The
incidence of
whooping cough
is highest in
under five
children.Infants

are susceptible to
infection from
birth because
they do not get
any
immunityfrom
birth. Incidence
is more in female
children than in

male children.
Prevalence
ismore in
children living in
overcrowded
homes and slums.
The disease
affects

trachea, bronchi
and bronchioles.

Magnitude of
the problem
Whooping cough
occurs in all
countries since
the beginning of
this century.

There has been a

marked and
continuous drop
in details from
whooping cough.
Pertussis is still
aclinically
serious illness,
with high

mortality and
complication
rates. Whooping
coughoccurs
endemically and
epidemically in
tropical
countries. Since
the reporting

of whooping
cough is
inadequate,
reliable
information about
the incidence of
this diseaseis
lacking in most
countries. About

10 percent of all
whooping cough
cases and
abouthalf of the
death occur in
children under
one year.

Prevention
and Control

The occurrences
of pertussis can
be prevented by
immunization of
children which
isdone in
combinations

with diphtheria
and tetanus.
Control of
pertussis can be
done by early
recognition of
disease which can
be done by

microscopic
examination of
secretions from
nose and throat
during catarrhal
andearly
paroxysms stage
provided this

facility is
available.
The child either
having or
suspected having
whooping cough
should be
isolated asfar as

possible. The
infants and
young children
should be kept
away from
cases.These
children must be
referred to PHC/
CHC so that

medical care is
given
andtreatment is
started as soon as
possible.
The usual
treatment is
administration of

antibiotic to
control secondary
infections.Usuall
y erythromycin
is given for ten
days, adjusted
according to
childs
weight(30-40

mg/kg in 4
divided doses).
Erythromycin is
also given to
contacts for
10days as a
prophylactic
measure to
prevent settling

of infection in
them
Clothes, fomities
should be
disinfected and
discarded
properly to

prevent spread
of infections.
Health workers
must be trained to
implement these
measures. Health
workers
musteducate

parents and
family members
for
immunization of
their children,
earlyrecognition
of disease,
treatment and
care of their

children,
prevention of
spread
of infection to
other children
and their care etc.
Community
health nurse must

provide adequate
supervision,
guidance for the
same.She must
educate and train
health workers
for prevention
and control of

whoopingcough
in children.

d)Tetanus
Tetanus is an
acute and highly
fatal disease. It is
caused by
clostridium tetani
which is aspore

forming bacteria.
The spores are
highly resistant
and can survive
for years in
thesoil and dust.
They can be best
destroyed by
steam under

pressure at 120
degree for
20minutes. The
organisms are
found in the
intestine of
herbivorous
animals such as
cattle,horses,

goats and sheep

and are excreted
in the faeces of
these animals.
The
organismsform
spores which get
mixed up with
soil and dust. The

spores get blown

up to
distant places
anywhere.Infecti
ons enter the
body through
injury which gets
contaminated.
The injury may

besmall like pin

prick, abrasion or
big and punctured
wound. The
injury may be
attained by a fall,
animal bite,
surgery etc.
Infections can

take place by
many other ways
for example
during delivery
and after
delivery, while
cutting the cord
and thereafter
byimproper care

of the cord,
extraction of
teeth, injections,
tattooing,
gangrenous
foot,otitis media
etc.
Tissue damage,
dirty and

anaerobic
conditions
predispose to
tetanus. Tetanus
can occur at all
ages. But the
incidence is high
in childhood.
The new born

baby can get

tetanuswhen the
umbilical is cut
with unclean
blade and when
the cord is not
cared
properly.The
tetanus

occurring in the
new born baby
is known as
Neo-natal
tetanus.
Theincidence
occurs more in
males than in
females and also

more in rural
areas than
inurban areas
mainly due to
use of cowdung
on muddy floors
and walls and
use of compost.
The incidence of

tetanus is
associated with
unhygienic
environmentalco
nditions and
unfavorable
sociocultural
practices. The
spores of bacilli

arecontinuously
discharged with
faeces of
animals in the
soil; manure is
used in
thegardens and
for agriculture.
Cuts and

injuries do
happen every
now and
then.Unhealthy
and aseptic
practices are
carried by many
people. All these
conditions predis

pose to
infection.The
usual average
incubation period
ranges from 6-10
days. But it can
be very short
(1days) or very
long (several

months)
depending upon
the germination
of spores
and production
of exotoxin.The
mortality rate is
very high (4080%). It is

highest
inneonatal
tetanus (80-90%).

Magnitude of
the problem
It is one of the
leading causes of
infant mortality.
5 to 10 percent of

neonatal deaths
inCalcutta were
due to tetanus.
Geographical
variation in
incidence has
been related
toclimate,
organic content

of soil, amount of
agricultural
activity and
prevalence of
localcustoms
tending to
promote
infection. The
incidence of the

disease in
Calcutta
during1971 was
24/ 100,000
population.

Prevention
and Control

Tetanus can be
prevented by
active
immunization by
tetanus toxoid of
all
antenatalmothers
and children
according to

national
immunization
schedule.
The
immunization is
done by
combined
vaccine in case

of children for
the firstthree
doses and first
booster dose as
DPT and for 2
nd

booster dose as
Dt.Theimmuniza
tion of mothers
and 3

rd

booster dose to
children is done
by
monovalentvacci
ne i.e. T.T
Active
Immunization of
mothers during
pregnancy also

helps
in preventing
neonatal tetanus
as immunity gets
transferred to
baby.
T.T
immunization is

done soon after

road injury
especially if T.T
immunizationsar
e not done with
in 5 years.
In addition, all
wounds and

injuries should be
thoroughly
cleaned and
covered
withsterilized
dressing
aseptically.

Active
immunization is
done by 5ml of
TT injection
simultaneously
which isrepeated
after six weeks
followed by a
booster dose

after one year to

get longlasting
effects.
It is essential
for health
workers to
encourage and
motivate

parents,
familymembers
and community
at large for
immunization of
all pregnant
women
andchildren
against tetanus,

to educate them
regarding proper
care of any kind
of injuries.
They must
supervise and
guide TBAs to
conduct safe

deliveries using
five cleansand
ensure support
for the same.
They must
educate
community
people about
theseriousness,

mode of
transmission and
prevention of
tetanus. The
community
healthnurse needs
to help, guide and
support health
workers in

carrying these
functions.

e)Poliomyelit
is
Poliomyelitis is a
crippling disease
as it causes
lameness. It is
caused by virus.

Thevirus is
found only in
human beings.
The source of
infections is
human faeces
and
or pharyngeal
secretions of an

infected person.
The disease is
most
communicable 7
to 10each before
and after the
onset of
symptoms. The
organisms from

the infected
personsare
excreted with
faeces usually
for 2-3 weeks
but the period
may prolong for
3 to 4months.The
main channel for

spread of
infection is fecaloral channel. The
infection is
spreaddirectly by
contaminated
hands and
indirectly by
using

contaminated
water, milk,
foodand by using
contaminated
articles. The
infection is also
spread by
infected
dropletswhich

are exhaled out

by coughing,
sneezing, talking
when the virus is
present in
thethroat during
acute phase of the
disease.The
poliomyelitis

was wide spread

in the world.
But by 1990s it
has
virtuallydisappea
red in the
developed
countries. In
India there has

been number of
epidemics
of poliomyelitis
in different states.
At present there
is almost
eradication status
of disease by
high level of

routine
immunization,
by pulse polio
immunization
and by
effectivesurveilla
nce.The disease
occurs in
children under

five years of age,

but mostly
between 6
monthsand 3
years. It occurs
three times more
in male children
than in female
children.

Over crowding
and poor
sanitation provide
increased
opportunities for
infection.The
incubation period
ranges from 3 to
35 days but

usually the
clinical signs
appear 7to 14
days after the
infections.Most
of the cases (9094%) who are
exposed to
infection and get

infection do not
showclinical
signs and
symptoms. They
are sub clinical or
said to have in
apparent
infection.They
can be recognized

only by
laboratory
investigations.

Prevention
and Control
Poliomyelitis is
prevented and
eradicated by

immunization of
all infants by
6months of age.
There are two
types of
vaccines which
are used. These
areinactivated
polio vaccine

(IPV) and Oral

Polio Vaccine
(OPV). Three
doses of OPVat
an interval of
one month each
are
recommended
by WHO

programme
of immunization
and the National
Programme of
Immunization in
India. The first
doseis to be given
at the age of six
weeks.

The
immunization
must be
completed by six
months; one
booster dose is
to begiven at 1218 months later.

This will help

prevent
occurrence of
polio between
theages of 6
months and 3
years.

The vaccine is
administered by
dropper by
gently squeezing
the cheeks or
by pinching the
nose of the child
to open the
mouth and let the

vaccine drop on
thetongue.
The health
worker must
educate parents
and family
members about
the importanceof

polio
immunization
and motivate
them for the
same.
Paralytic polio
can be recognized
on the basis of

clinical
manifestation.
The parentsand
family members
need to know so
that they can
avail medical,
nursing
and physiotherap

y services as
early as possible
to minimize or
prevent crippling.
Healthworkers
must be educated
and trained for
recognition of
polio cases so

that they canhelp

in early treatment
and care of
children with
paralytic
poliomyelitis.
It is very
important to do

active
surveillance of
acute flaccid
paralysis,
includingcauses
other than
poliomyelitis.
Each and every
case of acute

flaccid paralysis
must be reported
immediately to
the chief medical
officer with the
following
details:

Name, age and

sex of the patient.

Fathers name
and complete
address.

Vaccination
status

Date of onset of
paralysis and date
of reporting.

Clinical diagnosis

Doctors name,
address and
phone number.
Arrangement for
stool
examination
should be done

for isolation of
poliovirus
for suspected
cases of polio for
rapid case
investigation.
The nurse/ health
supervisor must

help and guide

health workers in
prevention
andcontrol of
poliomyelitis in
children in the
community.

f)Measles

Measles is a
worldwide
endemic disease.
It occurs more in
the winter
months
fromDecember
to April in the
form of endemic

in 2-3 years time.

It is an acute and
veryinfectious
disease. The
disease is caused
by virus.
Secretions from
nose, throat
andrespiratory

tract of children
with measles are
the source of
infection. These
secretionsare
infective 4 days
before
appearance and 5
days after the

appearance of
rashes.
Thedisease is
highly infectious
during this
period. It can be
transmitted to
other children
bydirect contact

by droplet
infection. The
children under 7
years are
susceptible
tomeasles
infection. But
children in the
age group of 6

months to 3
years are the
mostsusceptible.
It is rare in under
five months old
infants because
of antibodies
receivedfrom
mother during

pregnancy. Both
male and female
children are
equally
susceptibleto
measles
infection. An
attack of measles
gives life lasting

immunity to the
child ingeneral.
Second attack
occurs rarely.
The severity of
the disease
causing high
mortalityis more
in malnourished

children than in
healthy and well
nourished
children.The
average
incubation
period 10 days
but it ranges
from 8 to 16

days. The
commoncomplic
ations which can
occur during
measles include
bronchopneumonia,
diarrhea,otitis
media,

encephalitis
etc.depending
upon the
nutritional status
and general
bodyresistance
of the child.
Mortality is very
high in

malnourished
children.
Mortality
canoccur during
acute phase and
after the attack
within nine
months.

Prevention
and Control
The occurrence
of measles can
be prevented
completely by
achieving
animmunization

level of 95
percent and by
continuing
immunization of
children
of successive
generation.

As per National
Immunization
Programme,
immunization
must be done at
the ageof 9
months by
giving a single
dose of 0.5ml

of live
attenuated
vaccinesubcutan
eously.
Immunity
develops after
11 to 12 days of
vaccination and

gives 95
percent protectio
n.
During the
season when
measles occurs
children
suspected of

having
measlesshould
be isolated as far
as possible
before the
appearance of
rashes, and 7
daysafter the

appearance of
rashes.
Other children
should not be
allowed to come
in contact with
children
havingmeasles.

Prompt
immunization of
children from the
age of 5 months
onward at the
beginningof an
endemic is

essential to limit
the spread.
Health education
of people at
large to educate
about prevention
and control
of measles.

The child with

measles must be
under the medical
supervision,
given good
nursingcare,
given good
nourishing diet

to prevent
complications
and promote
quick recovery.
The health
workers must
immunize all
children

following all
precautions,
tomaintain cold
chain, safety of
vaccine and
aseptic
techniques.

They must
educate and
motivate parents
and family
members and
community
atlarge about the
immunization for
measles.

They must also

help family in
taking care of the
child with
measles, in
preventinginfecti
on to other
children and in

taking the child

to PHC/CHC to
avail medical
andnursing
service. They
must follow the
children in post
measles stage to
helpmothers to

take care of the

childrens
nutrition and
monitor their
growth
anddevelopment
and refer in case
there is any

problem for
timely actions.
The community
health nurse/
health supervisor
must help and
guide health
workersin

prevention and
control of
measles in
children in their
community.
They must
actively
participate in

prevention and
control of
measles when
requiredand felt
necessary. They
must educate and
train health
workers and

community peopl
e for the same.

g)Acute
Respiratory
Infection
(ARI)
Acute respiratory
infection causes
inflammation of

respiratory tract
from nose to
deepdown in the
lungs. Most of
the time infection
is mild
characterized by
cough and
cold but 10-25

percent of
children in the
developing
countries have
pneumonia
whichfrequently
causes death.
Death rates are
higher in young

infants and
malnourishedchi
ldren. On an
average a child
gets 5-8 episodes
of ARIs per
annum.In India
ARIs isone of the

leading causes of
death.
Acute respiratory
infections are
caused by variety
of bacterias and
viruses. At a
timethere can be
more than one

infection. In
developing
countries
measles and
whoopingcough
are the important
causes of ARIs.
The risk factors
which predispose

for
ARIsinfections
include climatic
conditions, poor
nutrition, low
birth weight,
crowding,environ
ment pollution
etc.Infection is

air-born and it is
transmitted by
direct (person
to person)
contact. The
clinical signs and
symptoms
includes running
nose, sore

throat,cough, fast
breathing,
difficulty in
breathing, fever,
noisy breathing,
wheeze chest.

Classification
of ARIs

According to
National Child
survival and safe
motherhood
programme
ARIs isclassified
under:-

The young
infants ( age less
than 2 months)

Very severe
disease

Severe
pneumonia

No pneumonia

Child aged 2
months up to 5
years

Very severe
disease

Severe
pneumonia

Pneumonia

No pneumonia
but cough and
cold

Management
of ARIs
First and
foremost, it is

very important to
prevent the
occurrence of
ARIs.This can be
done by
complete
immunization of
children
according to the

immunizationsch
edule. Also
vitamin A should
be administered
to children under
3 years of age.
Mother and
family members

should be
educated and
motivated for
immunization
of their children,
avoidance of
childrens
exposure to
chills, providing

dust free
andsmoke free
environment and
ensuring
adequate and
nutritious diet.
The mothers
and family

members must
trained to
recognize early
signs
of pneumonia
and to report
about the signs
immediately
.

Once the child

with cough and
cold visits the
health center,
through
assessment
of the childs
condition is

done by asking
questions,
making
observations
andexamination
of the child. The
question should
be asked to find
out whether the

childhas cough
and for how long,
whether the child
is able to drink or
not, if the baby
isa young infant
whether the baby
has stopped
feeding well,

whether the child

hasfever and for
how long,
whether the child
had any
convulsions,
short periods of
not breathing or
turning

blue.After taking
history,
observation and
examination of
the following
signs should
bedone:-

Breathing

It is very
important to
count respiratory
rate of the child.
The child should
be restingwhile
counting
respiratory rate.
The lower half of

the chest or back

should be
exposedwell to
watch the
respiratory
movements. The
counting should
be done for one
minute.Fast

breathing is
considered when
a child of:

Less than two

months has 60 or
more breaths per
minute.

2 months 12
months has 50 or
more breaths per
minute.

1 year- 5 years
has 40 or more
breaths per
minute.

Chest in
drawing
For young
infants, the mild
chest indrawing
is normal because
their chest wall is
soft.However,
severe chest

indrawing (very
deep and easy to
see) may be a
sign
of pneumonia.
When in doubt,
reposition the
child so that he is
lying flat on

mothers lap.If
the chest
indrawning is
still not clearly
visible, it is
assumed that the
child does
nothave chest
indrawing. Chest

in drawing is
significant only
when it is
present all
thetime and
definitely visible.

Noisy
breathing (
Stridor)
Look and listen
for harsh noise
when the child
breaths in.
Wheeze chest:

- Look for any

sign of difficulty
in breathing and
listen to
whistlingsound
which might be
there while
breathing out.

Abnormally
sleep or difficult
to wake: See if the child is
drowsy for most
of thetime and
does not wake
up.From
practical point of

view fast
breathing, chest
indrawing and
inability to drink
areconsidered
reliable signs.
Other signs
which signify
very severe

disease or
severe pneumoni
a are:

Child stopped
feeding.

Child is too
sleepy (drowsy)

or difficult to
wake.

Stridor when the

child is calm.

Wheezing chest.

Convulsions

Severe under
nutrition

A very young
infant who has
fever or feels
cold to touch.

Classification
and
Management
of ARIChild

age < 2
months
(Young
Infants)Check
for the
following signs
Stopped feeding
well,

convulsions,
abnormally
sleepy or difficult
to wake, stridor
in calm
infant,wheezing
in calm infant,
fever or low body
temperature

Identify it as:
Very severe
disease, if mostof
these signs are
present.
Take the
following
actions:

Refer
urgently
t o Hospital.

Give first
dose
o f Antibiotic.

Keep the baby

warmduring
transfer.

Breast feed
frequentlyduring
transfer.
Severe
Pneumonia, if:

Fast
breathing.(60 per
minute or more)

Severe chest
indrawing.

Refer urgently to
hospital

Give first
dose
o f antibiotic.

Keep the baby

w a r m during
transfer.

Breast feed
frequentlydurin
g transfer.

If referral is not
possibletreat
with antibiotic
andfollow
closely.

No Pneumonia
If

No fast
breathing. ( less
than60/min)

No severe chest
indrawing.Advis

e mother to
give homecare.

Keep baby warm

Breast feed
frequently

Clear nose, if it
interfereswith
feeding.Advise

the mother to
return if:

Illness worsens

Breathing is
difficult

Feeding becomes
a problem.

Child age 2
months up to
5 yearsCheck
for the
following signs
Drowsiness Chest
in
drawingDifficulty

in waking up
Stridor in calm
childConvulsion
Wheezing in
calm
childInability to
drink Severe
under

nutritionFast
breathing
Identify it as
:Very severe
diseaseif most of
the
signspresentsTak
e the
followingactions

Refer to
thehospitalimmed
iately.

Give one dose

of cotrimoxazole.

Treat fevere
if any.

Severe
Pneumonia,if
there is
chestindrawing.

Refer to
hospitalimmediat
ely.

Give one dose

of cotrimoxazole

Treat fever if any.

If referral is
not possible,
treatwithcotrimox
azoleand
followclosely.

Pneumonia if
thereis fast
breathing

Advise mother
togive home care.

Givecotrimoxazol
e.

Treat fever,
if present.

Advice mother
toreturn with
childin 2 days or
earlycondition if
getsw o r s e
f o r assessment.

No pneumonia
if thereis no fast
breathing,
nochest in
drawing.

If cough persists
for more than
30 days,refer for
assessment.

Assess and treat

other problems.

Advice mother
togive care.

Treat fever,
i f present.

Reassess the
Child in 2
DaysWorse:

Not able to
drink. Has chest
indrawing.

The same as
aboveImpro
ving:

Improved
breathing.

Less fever

Have other
danger signs.

Eating better

Refer
immediately to
hospital

Review antibiotic

Finish 5 days
of cotrimoxazale
h)

Diarrhoeal
Disease
Diarrhoea is an
acute or chronic
intestinal
disturbance
characterized by
increasedfrequen
cy, or volume of

lower movement.
It has been
defined as
passing of more
thanthree loose
motions in a day
or 24 hours. It
has been further
classified an

acute diarrheai.e.
lasting for less
than 21 days, and
chronic diarrhea,
lasting beyond
21 days,
whilechronic
diarrhea is
responsible for

the serious
problem of
malnutrition,
acute diarrhea
isresponsible for
death due to
dehydration.Diarr
hoea is caused
by variety of

bacteria such as
E.Coli, Shigella,
vibrio cholera
andsalmonella,
Rotavirus,
protozoans. The
organisms are
found in the
intestines of

bothhuman
beings and
animals. The
infection is
transmitted
through fecal-oral
route,
either water
borne, food borne

or by direct
transmission
through
contamitted
hands,
fingers,nails and
formites.

Magnitude of
Problem

According to
certain small
studies
conducted in
India it is
assumed as 100
millionchildren
(14.1 percent of
the total

population)
suffer from 300
million episodes
of diarrhea per
year. Ten percent
or 30 million
develop
dehydration and
one percent or

3million may
face
death.Diarrhoea
disease is a major
cause of death
and disease
amongchildren
under five years.
A child on

average suffers 2
to 3 attacks of
diarrhea
everyyear.

Mode of
transmission
Most of the
enteric
pathogens are

transmitted
primarily by the
fecal- oral route,
whichmay be
water-borne, food
borne or direct
contact.

Contaminated
Water
It is transmitted
through drinking
water of
contaminated
water from the
contaminatedwat
er sources, which

have been in
contact with
human excreta.

Contaminated
Food
Ingestion of
contaminated
food and drink

has been
associated with
diarrhoeal
diseases.Bottle
feeding could be
a significant risk
factor for infants.

Direct Contact

Person to person
transmission
readily takes
place through
contaminated
fingers
whilecarelessly
handling excreta
and vomit of

patients and
contaminated
linen.

Clinical
Manifestation
Clinical
features of the
diarrhea

depend upon
the severity of
the disease.
Dehydration

Little to extreme
loss of
subcutaneous fat.

Upto 50 percent
total body weight
loss.

Urinary output
decreases.

Poor skin turgor

dry skin and dry
mouth.

Sunken
fontanelles and
eyes.

High pulse

Behavioral
Changes

Irritability

Restlessness

Weakness

Pallor

Stupor and
convulsions

Respiration

Rapid,i.e
Hyperpnoea

Stools

Loose and fluid

in consistency

Greenish or
yellow green in
colour

May contain
mucus or blood.

Vomiting

Mild and
intermittent to
severe vomiting

Anorexia
Preventive
Measures of
Diarrhoea

Promotion of
environmental
sanitation which
includes safe
water supply,
safedisposal of
excreta, having
sanitary latrines,
avoidance of

defecations by
childrenhere and
there, protection
of food from
contamination.
Washing of
hands before
handling and

preparing food,
before eating and
feedingthe child,
after defecation
and cleaning the
baby after
defecation each
time.

Toilet training
and training of
health habits to
children.
Immunization of
children against
measles can
prevent 25

percent of
diarrhoealdeaths
due to measles.
Promotion of
exclusive breast
feeding for 6
months,
introduction of

supplementalfoo
d items after six
months, full and
nutritious diet by
one year
onwards.
Prevention of low
birth weights by

improving
prenatal and
postnatal
nutrition.
Education and
training of health
workers.

III. Problems
of
Neonatesa)Hy
per
bilirubinemia
This condition
refers to
excessive

presence of
bilirubin in the
blood. It is
indicated
as pallor of the
skin and eyes. It
is either due to
physiological
jaundice, RH or

ABOincompatib
ility.
Physiological
jaundice usually
disappears with
in days
with phototherap
y. Jaundice due to
RH

incompatibility
occurs due to 24
hours and
requires blood
transfusion.

b)Hypotherm
ia
The new born
baby may go

into
hypothermia
within one hour
of birth, with
thetemperature
(axillary) falling
below 36.5
degree c (97.7
degree F). This

happens
if proper
precautions are
not taken to
prevent chilling
of the baby. The
woman in
thefamily and
birth attendant

should be made
aware about
drying the baby
after
birth, providing
skin to skin
contact with the
mother and
initiating breast

feeding within
anhour of birth.
Hypothermia is
harmful to the
new born,
increasing the
risk of
themorbidity and
mortality.

c)Neo-natal
tetanus
Neo- Natal
tetanus is the
common
problem. It is
usually due to
sepsis caused
byuncleaned

delivery and cord

care. It is still
quite common in
the developing
world.According
to the WHO
estimates there is
considerable
decline in the

incidence of
NNTand
mortality due to
NNT in the
world. The greast
decline in NNT is
observed in
southEast Asian
countries.

According to
surveillance
report in India,
there has been
declinein the
reported cases
from 31,844 in
1987 to 4811 in

1999 (decline by
84.9%).
Thedecline is the
mainly due to
significant
increase in
immunization
coverage of

antenatalmothers
in the world and
in India.
Considering the
preventable
nature of NNT,
Whohas resolved
to eliminate NNT
by aiming to

reduce the
incidence to less
than 1 case
per 1000 live
births. The same
goal is accepted
by the Indian
Government.
The

followingactions
are implemented.
100 percent
coverage of
pregnant women
with two doses of
Tetanus Toxoid
(T.T.)

100 percent clean

deliveries.
Surveillance of
neonatal deaths
and
investigations of
tetanus cases and

deaths in
thecommunity.
Use of
information,
education and
communication
strategies to
promote 5

cleansi.e. clean,
surface, clean
hands, clean
surroundings,
clean blade/
scissors, clean
tieand clean cord.

d)Birth
asphyxia

Birth asphyxia is
characterized by
absent or
depressed
breathing at birth.
In
developingcountr
ies 3 percent of
all new-born

babies (3.6
million) develop
moderate or
severeasphyxia.
Of these, about
84000 die and
approximately
the same number
of themdevelop

severe epilepsy
and mental
retardation.
Difficulty in
initial breathing
is due tovariety
of reasons such
as prolonged or
obstructed

labour,prematurit
y, infection
etc.often it can
be anticipated.
The following
actions should be
taken to reduce
neonataldeaths

due to birth
asphyxia.
To keep ready the
necessary
equipments for
management of
birth asphyxia.

Clearing of air
passage
immediately as
the child is born.
Ventilating with
mask or bag and
mask.

Cardiac massage
when bradycardia persists.
Mouth to mouth
breathing when
necessary.

Training of
health workers
including TBAs
in the assessment
and management
of birth
asphyxia.

e)Oral
thrush

Oral thrush is
characterized by
white patches in
the mouth. It is
caused by
candidaalbicans
which is usually
present in the
vagina of some

women. It is very
important
tomaintain
personal hygiene
to prevent this
infection.
f)

Sepsis

The new born

baby is very
susceptible to
infection.
Within few
hours of
birth,staphylococ
cal may generate
colonies on the

babys skin and

in the nasal
passages andmay
cause infection
of the umbilical
cord, skin fold
such as axilla
and groin,
nostrilsetc. The

baby should be
protected from
being exposed to
infection. Any
person havingany
infection such as
upper respiratory
infection,
diarrhea, skin

infection
shouldnt
beallowed to
come in contact
with baby.
Personal hygiene
and general
cleanliness need
to be maintained.

g)The
infected New
Born
The child may be
born with
infection present
in the mother.
The child may
attain

thisinfection
either through
transplacental
circulations or/
and during the
course
of pregnancy
and delivery.
The various

infections which
the child can
have
includetetanus,
syphilis,
gonorrhoea,
hepatitis B and
C virus, and
HIV. Tetanus

can be prevented
by two doses of
T.T.immunizatio
n of all pregnant
women and by
observingfive
cleans for all
deliveries.
Congenital

syphilis and
gonorrhoea can
be prevented
byearly
recognition of
these diseases
among the
couples and

their treatment
and by
observing clean
and safe delivery
practices during
and after. But
usually these
diseasesare not
reported and

treated properly.
It is also not
possible to
recognize the
congenitalsyphili
s because
clinical signs do
not occur soon
after birth. But

treatment can
bestarted in
doubtful babies
and especially in
those cases
where
monitoring is
not possible. Ne
w born can be

infected with
hepatitis if the
mother is chronic
carrier of
hepatitis Bvirus.
Transmissions
occur through
blood and genital
secretions.

Therefore the
newborncontract
infection during
the immediate
perinatal period.
If the child gets
the infection,he
or she becomes
carrier and

develops chronic
hepatitis,
cirrhosis or
primary cancer
of the liver
during
adulthood.Perinat
al transmission of
the hepatitis B

can be prevented
bycombined
seroprophylaxis
(2ml of anti HBs
gamaglobin)
combined with
anti- hepatitisB
vaccination
within 12 hours

of birth. The
vaccination must
be repeated at 1
and 2months and
then at one year
of age. Though it
is found to be
effective but
practically ithas

not been found

feasible firstly
because it is
difficult to
identify and
detect
motherswho are
carriers of this
infection and

secondly because
of low cost
involved. New
born may also
be infected with
HIV if the
mother is HIV
positive. About
30 percent of the

babies born to
HIV positive
mothers get
infected with
HIV. Like
inhepatic B,
transmission
occurs through
blood and

genitals
secretions. The
risk transmissio
n depends upon
the severity of
infection in
mother. The
possibility
of transmission

of infection
through breast
milk is also there.
Therefore
whether to
breastfeed the
baby or not, it is
to be considered
for the survival

of child
especially
for socioeconomi
c ally poor and
underdeveloped
people. BCG
vaccination is
contracted
inthese children

and shouldnt be
given unless
confirmed
otherwise.
Unlike hepatitis
B,no preventative
treatment so far is
available for the
new born.

2.
FACTORS
INFLUENC
ING
MATERNA
L AND

CHILDHEA
LTH
Maternal Age
As maternal age
advances, so does
the rate of
aneuploidy. The

result is increased
ratesof pregnancy
loss and birth of
infants with
chromosomal
anomalies. Most
women andmen
are aware that
advanced

maternal age
(older than 35
years) may affect
a
pregnancyadverse
ly. This
awareness is the
direct outcome of
the adoption of

practice
standardsthat
obligate
obstetricicians,
gynecologists,
and womens
health nurses to
appropriatelydiss
eminate this

information and
the considerable
media exposure
about this
issuethrough
public service
campaigns, news
programs, and
storylines in

popular entertain
ment.Conversely,
the general public
health care
providers are less
aware that
advanced paterna
l age (older than
45 years at

conception)
unfavourably
affects fetal
growth
anddevelopment.
People of
advanced
reproductive age
require

information about
the possible
outcomesfor a
child conceived
with their genetic
gametes. The
nurse should
offer education
andcounseling

using incidence
tables for
chromosomes
anomalies
associated
withadvanced
maternal age and
review
characteristics of

disorders that
may occur
through paternal
transmission of
spontaneous new
mutation as a
result of
advanced
paternalage.

Sexuality
Factor
Both the client
and her partner
may express
concerns about
sexuality and
intercoursedurin

g pregnancy.
Although there is
no reason why
the healthy
woman need
abstainfrom
intercourse or
orgasm during
pregnancy, some

sources suggest
that women
shouldavoid
coitus and
orgasm in the
last 4 weeks of
pregnancy.
Regardless of
suggestionsstudie

s have found that

the frequency of
coitus decreases
as pregnancy
progresses.Interc
ourse or orgasm
is contraindicated
in cases of known
placenta previa,

or
rupturedmembran
es. Nipple
stimulation,
vaginal
penetration, or
orgasm may
cause uterine
contractionsseco

ndary to the
release of
prostaglanins
and oxytocin.
Therefore
women who
are predisposed
to preterm labour
or threatened

abortion may
choose to avoid
intercourse.Devel
opment of
sexuality is an
important part of
each persons
psychosocial
identity,integrate

d sense of self,
reproductive
capacity and
ability to fulfill
role functions
insociety.

Nutrition

During
pregnancy
changes must
occur to ensure
that gestation
progresses and
bothmother and
fetus remain
healthy. These

changes involve
synthesis of new
tissues
andhormonal
variations to
regulate
essential
processes.
Nutrition has

critical role
in pregnancy
outcomes
maternal
nutritional status
at conception and
throughout
gestationgreatly
influences not

only the mothers

health but also
that of the fetus.
Although
solidnutrition
cannot guarantee
a healthy
pregnancy, it can
certainly

minimize
problems.Adequa
te folate status,
which helps
prevent neural
tube defects, and
control of
bloodglucose
level, which

improves the
abilities to
conceive and to
give birth to a
healthynewborn.
Women require
proper nutrition
and normal
endocrine

function for
normal
fetaldevelopment
. Women
specially require
additional
vitamins and
minerals to
supportfetal

growth and
development.
Especially
important is
additional folic
acid to reducethe
risk for neural
tube defects.

Environmenta
l Factor
Environmental
factor also
influence on
maternal and
child health. So
we have to
knowabout the

environment in
which the woman
and partner reside
and work.Men
exposed to toxic
substances such
as heat, radiation,
viruses, bacteria,
alcohol,

and prescription
and recreational
drugs are more
likely to have
decreased
morphologicallya
nd genetically
normal sperm in
a single ejaculate.

This results in
reproductive
failure preconcep
tion and post
fertilization.Wom
en exposed to
similar toxic
agents
experience

diminished
ovarian reserver,
poor endometrial
lining
development,
and abnormal
fetal
development.
Likewise,

chronicand acute
diseses decrease
fecundity and
increase fetal
wastage.

Psychological
Factor

Virtually all
culture
emphasizes the
importance of
maintaining a
psychological
andagreeable
environment for
a pregnant

woman. An
absence of stress
is important
inensuring a
successful
outcome for the
mother and baby.
Harmony with
other peoplemust

be fostered, and
visits from
extended family
members may
be required
todemonstrate
pleasant and no
controversial
relationships. If

discord exists in
arelationship, it is
usually dealt with
in culturally
prescribed
ways.Certain
environmental
factors such as
emotional stress,

anxiety, fears,
frustrations, brok
en homes,
poverty and
many others can
lead to mental
illness. The
psychosocialenvi
ronment at home

or school is an
essential factor
for health.
Children exposed
tohappy and
healthy homes
make them
physically and
mentally healthy.

Other
factorsaffecting
the health status
of children
include
community and
social support
measuresetc.

Pregnancy is the
gestational
process.
Comprising the
growth and
development
with awoman of
a new individual
from conception

through the
embryonic and
fetal periods
to birthing
environment.
However, an
increasing
amount of social
science and

midwiferyresearc
h has explored
the issue of social
support for child
bearing women
and the rolethat
the maternity
services might
play in offering

or facilitating
rather
thanundetermini
ng such support
to
women.Support
must be
individualized
and tailored to

the womans
changing needs
duringlabour.
Emotional
support includes
physical
presence and
words of
affirmationreass

urance,
encouragement
and praise.
Comfort
measures are any
hands on
activityaim at
decreasing the
physical

discomfort
(pain, hunger
and thirst) of
labour.Informati
on and advice
ensure that the
woman is aware
of what is
happening and

of techniques that
may help her to
cope.

Ethnic and
Socio Cultural
Factor
Culture and
family must be

viewed
simultaneously
for, regardless of
the family type,
itremains the
basic unit of
society and
influences human
development over

the life span.The

older adults in
these families
often have
significant roles
in health and
child
care,household
maintenance, and

decision making.
Multiple care
takers are
available to
helpwith
childrearing and
discipline.Sociali
zation is an
early family

function.
Socialization
includes all the
learningexperien
ces of early life.
Home remedies
and folk care
practices for
prevention

of illness,
maintenance of
health, and
curative
purposes remain
primary sources
for mostfamilies,
regardless of
ethnic and

cultural
backgrounds.Co
mmunication
patterns are
influenced by a
familys culture.
Religious beliefs
and practices
are part of

cultural and
familial
heritage and
influence health
care behaviours.
Within the
neighborhood
and community,
health families

tend to
associatefreely
with community
groups and
institutions to
identify
resources and
receiveservices
as needed by

them. The
ability of the
healthy family
to seek help
throughcontact
with others
appears related
in part to the
familys

perception of
itself as a partof
a whole and to
their successful
dealings with
the larger
community in
meeting physical
, psychologic,

and social
requirements.The
value of the
children varies
greatly,
depending on
the meaning
each
societyattaches

to children.
Health values
and beliefs are
also important in
understandingrea
ctions and
behaviour. If a
culture views
pregnancy as a

sickness, certain
behaviourscan be
expected,
whereas if
pregnancy is
viewed as a
natural
occurrence,
other behaviours

may be expected.
Prenatal care may
not be a priority
for women who
view pregnancy
as a natural
phenomenon.Ma
ny cultural
variations in

prenatal care
exist. Even if the
prenatal care
describes
isfamiliar to a
woman, some
practices may
conflict with the
beliefs and

practices of
asubculture group
to which she
belongs. Because
of these and other
factors, such as
lack of
transportation,
and poor

communication
on the part of
health care
providers,
womenfrom
many such
groups do not
participate in the
prenatal care

system. Such
behaviour may be
misinterpreted by
nurses as
uncaring, lazy or
ignorant.
A concern for
modesty is also
a deterrent to the

seeking of
prenatal care for
manywomen.
For some women
exposing body
parts, especially
to a man is
considered
amajor violation

of their modesty.
For many
women, invasive
procedures, such
asvaginal
examination,
may be so
threatening that
they cannot be

discussed, even
withtheir own
husbands. Thus
many women
prefer a female to
a male health
care
provider.Althoug
h pregnancy is

considered
normal by many,
certain practices
are expected
of women of all
culture to ensure
a good outcome.
Cultural
prescriptions tell

women whatto
do, and
prescriptions
establish taboos.
The purposes of
these practices
are to
preventmaternal
illness resulting

from a
pregnancy
induced
imbalanced state
and to protectthe
vulnerable fetus.
Prescriptions
regulate the
womens

emotional
response,
clothing,activity
and rest, sexual
activity, and
dietary practices.

Lifestyle
Factors

The health of an
individual has
direct
relationship to the
lifestyle. It is
nothing but just
away of living. A
person who has
healthy practices

of day to day
living will
remainhealthy.
Those people
who follow the
healthy life styles
are much
healthier than
thosewho follow

injurious life
styles. The way
of life of people
in a community
and
their individual
life style also has
a significant
impact on

health.Health is
related deeply to
life- style which
includes ways of
living, personal
hygiene,habits
and behaviour. A
healthy lifestyle
helps to promote

health and poor

lifestyle hasill
effects on health.
Lifestyles are the
most critical
modifiable factor
influencing
thehealth today.
Life style refers

to a persons
general way of
living, including
livingconditions
and individual
patterns of
behaviour that
are influenced by
socioculturalfact

ors and personal

characteristics.Lif
e styles choices
may have
positive or
negative effects
on health.
Practices that
have potentially

negative effects
on health are
often referred to
as risk
factors.E.g. over
eatingGetting
insufficient
exerciseBeing
over viewing are

closely related to
the incidence of
heart disease,
diabetes
andhypertensio
n. Excessive
use of tobacco
is clearly
implicated in

lung
cancer,emphyse
ma and
cardiovascular
diseases. These
lifestyle risk
factors have
gainedincreased
attention because

it is known that
many of the
leading causes of
death. Thisalso
represents a huge
impact on the
economics of the
health care
system. Therefore

itis important to
understand the
impact of
lifestyle
behaviours on
health status.
Nursescan
educate their
clients and the

public on
wellnesspromoting
lifestyle
behaviours.

Factors
Influencing
Maternal and

Child Health
Lifestyles
Proper nutrition
and exercise.
Healthy sleep
patterns.

Adequate rest.
Healthy coping
with stress.
Ability to use
family and
community

support and
resources.
Health promotion
progress in
community

Educating school
children about the
food guide.

Encouraging the
provision of
healthy snacks.

Well balanced
meals in the
home.

Fitness program
for all ages.

Promotion of
community play
grounds in the
community.

Establishing
networks of
support in the
community.

Life enhancing
activities

Meaningful work

Creative outlet

Interpersonal
Relationship

Recreational
activities

Opportunity for
spiritual and
intellectual
growth
Mental Health
Promotion
interventions

Arts and crafts

classes
Encourage
creative
expression
Community event
sports events.

Volunteer
programs
encourage
community
participants.
Personal hygiene

Washing hands
with soap and

water before
eating.
Avoidance of
excess salt, fats,
sweets and
cholesterol
containing items.

Consumptions of
fiber- rich foods.
Avoiding of
having tobacco,
alcohol, drugs of
addiction.

Indulgence in
safe sex practices
Practicing
relaxation
techniques.
o

E.g. yoga,
Mediation

Health education
is an important
aspect to change
life style and
practicing
thehealthy ways
of living.

Daily routine
work

Bathing

Washing of hair
and clothes

Care of teeth, ear,

and eyes.

Eating habits

Exercise

Sleep

Rest

Avoid smoking
and drinking

Care of posture

The school
children must be
taught good
health habits and
include health
topicin
curriculum.

Health education
is a basic element
of all health
activity.

Changing views
of people

Changing
behaviour of
people

Changing habits
of people

Examples of
Healthy
Lifestyles

Choices of
Maternal and
Child Health
Regular exercise
Weight control

Avoidance of
saturated fats
Alcohol and
tobacco
avoidance
Seat belt use

Immunization
updates
Regular dental
check up
Regular health
maintenance

Regular
exercise
Regular routine
exercise is very
important in
human life.
Regular exercise
makes the body
healthy. Regular

exercise helps in
maintaining the
muscle tone,
preventing
fromdiseases.
During the
antenatal period
the pregnant
mother can do

light exercise
daily.

Weight
control
There is need to
control the
weight to
maintain healthy

life style .In

obese people
theexcess weight
leads to happen
different diseases
like cardiac
disease,
hypertension,dia
betes etc.

Avoidance of
saturated fats
These saturated
fats are not good
for health. These
fats will lead to
accumulation in
our body which

affects the
healthy life. The
mother and the
children should
be avoided
of taking
saturated
food.Example of
saturated food

like burger, oil

junk foods,
noodles, deep
fried food etc

Alcohol and
tobacco
avoidance

Excessive use of
alcohol and
tobacco is clearly
implicated in
lung cancer,
emphysema,cardi
ovascular disease,
pulmonary
diseases,

gastrointestinal
disease, cirrhosis
of liver,hepatitis,
reproductive
disorders
(infertility).
Tobacco smoke
contains
differentchemica

l substances of
which it produces
cancer. Tobacco
is the second
major cause
of death in the
world. Smoking
produces peptic
ulcer by

increasing acid
secretion.
Therole of the
nurse in
avoidance of
alcohol and
tobacco through
education,
givinginformatio

n and cessation
efforts etc.

Seat belt use

Seat belt safety
should be
maintained to
prevent from
accident while

driving car,
busetc.Especially
during pregnancy
the mother
should have seat
belt.

Immunization
updates

Immunization is
very necessary
to protect from
the six major
killer diseases
liketuberculosis,
tetanus,
diphtheria,
whooping cough,

measles and
poliomyelitis in
thechildren.
After having
immunization the
update should be
done
appropriately.
Thedetail of

immunization
should be
updated for not
to miss any dose
which may help
tomaintain
healthy life style.

Regular
dental check
up
Regular dental
check up should
be done to know
the condition of
the teeth and
to prevent from

dental carries.
Regular dental
check up should
be done every
interval of
6months.

Regular
health
maintenance
Regular health
check up which
includes
monitoring of
Blood Pressure,
blood

sugar,closterol
level and follow
up for the preexisting
problems.

Gender
In some society
there may be the

discrimination
between the male
and female baby.
If the mother
having a male
baby the family
will provide more
care and attention
towardsthe

mother and baby.

And if the
mother having a
female babies the
family
memberswill
provide her less
care and
attention towards

the mother and

baby. So gender
alsoinfluences
the maternal and
child health.

CONCLUSIO
N
Maternal and
child health is
recognized as one
of the significant
components of
FamilyWelfare.
Health of both

mother and
children is a
matter of Public
Health concern. It
isalso being
observed that the
deaths of mothers
and children are
the major

contributorsto
mortality in any
community in
India.The
maternal health
status differs
tremendously
from place to
place and in the

same place. It is
assessed in terms
of maternal
health problems
(maternal
morbidity)
andmaternal
mortality. The
factors which are

responsible for
maternal health
problems
i.e.maternal
morbidity and
maternal
mortality
include poverty,
ignorance,

illiteracy,malnut
rition, age at
marriage and
pregnancy, the
number and
frequency of
child bearing and
the number of
unwanted

pregnancies and
abortions, lower
status and
worthof women
in society, lack
of access to
quality maternal
health/
reproductive

healthservices,
gender
discrimination.Th
e different
factors which
influence the
maternal and
child health are
age,

gender,sexuality,
sociocultural
factor,
environment,
nutrition etc.

JOURNAL
RESEARCH
ABSTRACT

Assessment
and Utilization
of Maternal
and Child
Health and
FamilyWelfare
Services

among Rural
Women.
This study was
conducted in
selected primary
health centers
and its health
subcentres areas
of Pondicherry

health unit
district. Out of
250 mothers
selected,
208mothers were
delivered and
given birth to a
baby and 42
mothers who

were pregnant.
Astructured
interview
schedule was
used for data
collection and
analysis was
done,
thecollected

data were
analyzed and
found out the
main out come,
Association
of demographic
variables,
awareness of
MCH and family

welfare services
and the extentof
utilization of
services during
perinatal period.
The conceptual
frame work
adoptedfor the
study was based

on systems
model that
influences the
factors that
intervene inthe
utilization of
maternal and
child health
services. The

infant mortality
was found to be
33.5/1000 live
births which was
low, when
compared to
National average
(62/1000live
births) and it was

statistically
significant (P<
0.000). The most
causes of
infantmortality
identified were
prematurity,
asphyxia, and
low birth weight.

The mother
had poor
knowledge in
purpose of
immunization,
Vaccine
Preventable
diseases, high
risk factors,

antenatal diet,
family welfare
methods and
warning signs of
pregnancy.
Thoughthe
government has
given top priority
in

implementation
of MCH
Programmes,
thewomen were
not aware of
many health
programmes
related to mother
and child

healthand had
poor knowledge
in existing
programmes.

BIBLIOGRA
PHY
BT
Basavanthapa,
Community
Health
Nursing,

2nd Edition,
Chapter11,Maternal and
Child Health,
Published by
Jaypee Brothers
Medical
publishers,

2008,Page No.355-560.
Krishna Kumari
Gulani,
Community
Health Nursing
(Principles
andPractices),

1
st

Edition
,
Chapter-11,
Maternal and
Child Health,
Published
byKumar
Publishing

House, 2005,
Page No.: 339
366.
Wong
Hockenberry
Wilson and Perry
Lowdermilk,

 Maternal
Nursing Care
,3
rd

Edition,
Chapter- 11,
Health
Problems of
Children,
Published by

MosbyElsevier,2
006, Page
No:1444-1448.
S Kamalam,
Essentials in
Community
Health Nursing
Practice

,2
nd

Edition,Chapter15, Maternal and

Child Health,
Published by
Jaypee Brothers
MedicalPublisher
s, 2005, Page
No.: 403-425.

Potter Perry,
Fundamental
Of Nursing
6
th

Edition, Chapter
9, caring
for Families,
Page No.: 99.

Judith Ann
Allender
Barbara Walton
spradley,
Community
Health Nursing(
Promoting and
Protecting the

Publics
Health),
6
th

Edition, Chapter35,Clients with

mental Health
Issues and
addictions,
Lippincott

Williams and
WilkinsPublisher
s, Page No.: 842.
B. Sridhar Ras,
Community
Health Nursing
,1
st

Edition, 2006,
Chapter-2,Health
care, Disease,
Levels of
prevention,
AITBS
Publishers, page
No.: 20, 15.

Sunita Patney,
Textbook of
Community
Health Nursing
, First Edition,
2005,Chapter
11, Concept of
Health, Modern

Publishers, Page
No.: 138, 134.
Berman, Snyder,
Kozier, Erb,
Fundamentals
of Nursing
(Concepts,

process
andpractice)
,8
th

edition, Chapter
17, Health,
wellness and
Illness, Person
EducationPublish

ers, Page No.:

301.
Sally B. Olds
Marcia L.
London Patricia
A. ladewig,
Maternal
NewbornNursin

g ( A Family
Centered
Approach)
,2
nd

Edition, Chapter3, Dynamics

Of Family Life,
Published by
Addison

Wesley
Publishing
Company,1984,P
age No:42-43.

JOURNALS

Prof.Mrs.S.Kama
lam, Principal,
Kasturba Gandhi
Nursing College,

M.G.M.C andR.I,
Pillaiyarkuppam,
Pondicherry
Journal of
Nursing,
PJN Volume 1,
Issue 2,Sep- Nov
2008, Page No:
25.

Mrs. S.
Vijayalakshmi,
Nightingale
Nursing Times
, volume 3, Issue
10, January2008,
Page No: 24.

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