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CURRENT STATUS OF CHILD HEALTH IN INDIA Introduction Childhood is the formative period in human life,subjected to various intrinsic and extrinsic influences affecting their survival ,health and disease.State of child health in a community expects its overall socioeconomic development and health concerns.A child has beeen defined as an individual <18 years of age,through conventionally ,a paediatrician in india looks after the health of children till 12-14 yrs . From the child health perpectives,childhood is not homogenous period but includes various phases of growth and development with unique physical mental and social health dimensions during each phases. According to national family health survey ii children constitute 40 % indias population ,including 3%,11%preschoolers and 24%school children <14 yrs.Another 10% population is in 15-19yrs of age. Indicators of child health Status of child health in a country is reflected in various morbidity and mortality indicators and their changes over a period of time. Morbidity indicators Morbidity indicators are more reliable pointers of community health than mortality indicators.Although community data regarding patterns of child hood mortality in india is limited due to poor reporting system ,hospital data identifies four major causes of post neonatal morbidity in indian children.Acute respiratory tract infections 30%maturation 25%acute diarrhoel diseases and vaccine preventable diseases eg. Tuberculosis and measles.Many of these problems are interelated and coexist in the same child seeking health care. Like any other country ,morbidity profile is not static in india and keep on changing with overall development in socioeconomic and environmental status as well as child health cure awareness / facilities in the community.recent years have been substantid decline in

incidence of infectious and nutritional disorders.with simultaneously rise in non infective illness eg.systemic diseases and accidents due to changing life style and other ecological factors. Mortality indicators are relatively better defined and documented.it is estimated that 30-40%of all death in india occur during childhood of which 50%occur in first five years .20% in first month and 10%in first week of life. Neonatal and post neonatal mortality rate ,infancy includes two crucial phases of human life neonatal and post neonatal period with diverse child health problems.IMR denotes addition of neonatal mortality rate and post neonatal mortality rate which may be computed separately.Current MMR and PNMR in india is 39/1000 and 18/1000 live births,respectively. Last century has witnessed a sharp fall in IMR predominantly due to delivery post neonatal mortality rate after better control of exogenous factors. Under five mortality rate is a sentsitive indicator of the overall development of the community ,as majority of its causes eg. Malnutrition and infection depend upon the socioeconomic status ,environmental hygiene and child health awareness in population .it is defined as the ratio of annual deaths <5 years of age and total live births in the same year ,expressed as a rate per 1000 live births. In india ,under five mortality has shown marked decline during last few decades due to overall socioeconomic development ,easier acccess to child health care and control of infectious diseases. Causes of child hood morbidity and mortality Etilogy of child hood morbidity and mortality varies with age and may be divided inti two major groupsendogenous causes eg.low birth weight,predominantly responsible for neonatal morbidity and exogenous causes eg-infection and malnutrition which usually affect beyond the neonatal period. Rapid improvement in mortality indicators during the last century is largely attributable to be better control of exogenous factors.endogenous causes are more difficult to contro and

holistic strengthening of antenatal ,intranatal and post natal services. With relative control of common illness ,new causes are emerging as important contributors ,of child hood mortality and morbidity in india. Eg-congenital malformation ,immunological disorders ,newer injections.eg-HIV/AIDS and mental health problems. Determinants of child health Child health in a community is influenced by various environmental factors ,which account for geographic and demographic differences in morbidity and mortality .Important adverse factors for child health in india include 1. Maternal factors Eg- young maternal age ,maternal malnutrition and illnesses ,repeated pregnancies,short birth spacing etc 2. Socioeconomic factors Eg-poverty ,urbanisation ,large family size,female size,female illeteracy ,girl child,illegitimate pregnancies etc. 3. Cultural factors Eg-early marriage ,improper infant feeding practices eg-top feeding ,harmful child care customs/taboos etc 4. Environmental factors Eg- over crowding unsafe water suppply and excreta disposal ,poor personal and environmental hygiene,stressful family environment eg-broken families etc. 5. Health care factors Eg- inadequate antenatal care,unsafe/untrained deliveries,poor immunisation coverage,inadequate access to health services etc specially in rural areas.

Three most important determinants of poor child health in india and other developing countries are also denoted PPE spiral population,poverty,-explosion and envronment. Internal startegies for child health Since independence ,a plithora of targeted child health programs were launched in india with periodic reviews and modification while earlier programs were largely sectorail ,intersectotal coordination is hall mark of curremt strategies in child health care.some important aspects of these efforts area as follows. 1. General population measures Socio economic development ,population control,environmental sanitation,promotion of female literacy 2. Reproductive female health resources Nutritional health care of reproductive females,adequate birth spacing 3. Antenatal care Regualr antenatal care ,at risk approach for high risk pregnancies. 4. Perinatal care Safe clean delivery by trained attendants ,essential newborn care,promotion of breast feeding . 5. Post natal care Universal immunisation ,growth monitoring and promotion ,early diagnosis and treatment of common illness ,promotion of low cost tools eg-ors 6. strengthening of health care system Low cost medical care,general health care programme eg-RCH,ICDS,disease targeted programs eg-malaria control ,group targeted programs eg-street children

ETHICS IN PAEDIATRIC CARE The approach to the ethical issues that arise in paediatric practice must include respect for both a parents responsibility for the life and the health of a child and a childs developing capacity and autonomy. Informed consent parental permission and child assent. It is a voluntary decision to go forward on a health related matter.health care practinioners are legally and ethically obligated to abide by the consent agreement unless the person later withdraws or modifies consent. Issues in consent with children Whether children are developmentally able to give informed consent ,in particular to an adult? An evaluation of childs experience ,maturity,development,communicationand intelligence are carried out. For this reason most states have an age of consent under which a child is deemed unable to give consent. Who can consent to treatment for a minorchild? Human subjects research guidelines for children require that the permission of parents or guardian must be obtained. A person below the age of consent may agree to treatment ,knowing all the consequences but his or her consent is deemed invalid. Age of consent According to section 90 IPC ,a child less than 12 yrs of age or insane person cannot give valid consent.

Howeever section 07 IPC metion 18yrs as the age for giving consent for acts not intended and not known to be likely to cause deaths or grevious hurt. Childs autonomy In the last 2 decades ,there have socio political development around the world to increase the childs legal authority and to give the child ,his or her own voice. Some people argue that mature children should be allowed to make their own decision without their parents permission ,even without their parents awareness. In indian culture ,the authority of parents is near absolute .children are not to exercise any consent /opinion in normal course DNR orders (do not resustitate) DNR orders are ethically appropriate when the borders of resustitation exceed the expected benefit.we have a duty respect the wishes of the child and family ,to do good((benefiecience) and to avoid harm (non malficience)which may lead to conflicting consideration for a child with a DNR orders. When are DNR orders are witten? In the judgement of the treating physician ,an attempt to resusucitate the child would not benefit the child. The parent or surrogate decisison maker expression his or her preference that CPR be withheld in the event that the child suffers a cardiopulmonary arrest ,as long as this is in accordance with the childs best interests. Parental permission: The concept of parental permission reflects this shared decision making involved in paediatric health care.In any given instance ,the decision of what is or not in a childs best interest may be difficult ,especially given the diverse views of acceptable child rearing and child welfare.

Child assent Respect for children must account for both a childs vulnerability and developing capacity .Thus this respect encompasses both the protective role of parental permission and the developmental role of child assent. Non-malficience Non malficience is derived from latin and means do not harm.All medical interventions carry the risk of harm and avoidance of harm is not always easy to achieve.The moral duty to avoid harming others applies not only to health care professionals but to every one in the society. Beneficience Beneficience ,which also derives from latin ,means do good.The moral duty to do good does not apply to everyone and to everyone and to every situation in socety ,such a demand would be beyond any ones ability .Nurses entering the profession knowingly take on the duty to do for patients what over good lies within their power. Justice The principle of justice applied to health care most usually relates to the fair and equitable use of resources.There is an inherent tension between the desire and duty to do ones best for each patient and conflicting claims for resources between patients. Veracity Veracity means truth.Philosophical writers subsume the ethical principles of veracity within the other ethical principles explained above.The reason for this is that either telling the truth can harm ,do good ,uphold justice and show respect for autonomy.

Cultural issues Importance of culture to medical practice Culture is a communitys or a societys shared history ,beleifs and values ,including frameworks for learning ,understanding events and history ,and defining concepts such as prosperity ,success,knowledge and health .cultures are dynamic and interactive,so that even as individuals act within a culture,those action effect changes in that culture. Newly recognised cultural groups Failure on the part of paediatrician to recognise accepted language and frame of references of newly recognised cultural groups may result in the unintentional use of offensive terminology or assumptions ,leading to loss of the physicians credibility or non compliance from the patient. Culture of the medical profession The profession of medicine also has a district culture .Like other cultural groups ,physicians share a common history ,admitting the same role models ,sharing the same preparatory course that must be mastered for entrance into training for the profession and subscribing to a common meaning of competence in medical practice .physician learn a new way describe health and illness ,requiring a new vocabulary and a prescribed pattern to the narrative history ,which is not shared by those outside medicine. Cultural competence Recognising that physicians and patients bring to their interaction , personal and professional values from multiple cultural system ,which have significant implication for the delivery of health care ,has lead to recognition of the need for physicians cultural competence. Among the proposed framework for cultural competence ,campinha bacotes model is the most frequently cited. 1. learning to value and understand other cultures. 2. learning basis fundamentals of other cultures

3. Developing the ability to apply other cultures knowledge in patient encounters. 4. seeking exposure to cross cultural interactions 5. Being motivated to achieve all of the previous. Cultural awareness Recognition of the importance of differing cultural expectation and explanation is critical to a pediatricians sucessful with the patients.failure on the part of paediatrician to realise that a mother may not feel comfortable or competent to make a decision about the health of her child may result in an apparent non compliance on the part of the mother. Cultural knowledge Physicians and patients having different definitions of health and illness and different concepts of the origins of diseases and therapeutic responses.understanding the patients perspective will both increase the likelihood of correct diagnosis and patient adherence to therapy and decrease the probability of diagnosis. Cultural skill Describing a diagnostic or therapeutic course of action that respects cultural beleifs but is consistent with good medical practice can be challenging. Central to cultural skillis the employment of language fully comprehended by the childs parents.professional interpreters should be avaliable and accessed to overcome the language barriess Cultural encounters While cultural knowledge may be acquired through didactic training ,the developmant of cultural skills requires experience that can only be gained through repeated cultural encounters.cultural knowledge and participation in diverse educational setting predicted the cultural awareness. Cultural desire

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Cultural competence is not something that can be acheived and retained in the absence of continued effort.The recognition that culture is integral to health and healing,and to diseases and sickness is central to the conceps of cultural competence

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Trends in paediatrics and paediatric nursing Remarkable changes have occurred in the field of paediatric nursing in recent years due to changing needs of society ,medical and technological advances ,political interests and changing trends within the nursing profession.other influencing factors are consumers demands ,increased public awareness ,and greater understanding of child health problems along with psychological aspects of illness and hospitalization. Curent trends Modern approach of child health care emphasizes on preventive care rather than curative care .current trends are as following: Family centered care Enabling Empowerment High technology care Evidence based practice Traumatic care Cost containment Prevention and health promotion.

Family centered care Acceptance of family centered care of children impart more responsibility on paediatric nursing and paediatric nurse.nurses are working in liason with the health team and family to prepare mutually developed plan of care and to minimize psychological trauma in relation approach of child care. Through the family centered care ,the nurse considers and treats the child in the context of the family and recognises the family as primary and continuing providers of care for the child . Parents have varied responses to the childs illness.They may initially deny that their the child is ill ,especially if the illlness is serious.the period of deny may be followed by anger.The anger may be directed towards nurse,at family members or even at god,when the immediate crisis over ,a period of depression may occur.At this point the parents are exhausted both

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physically and psychologically.The nurse need to be aware of parents feelings and to listen closely what is said.the nurse can then assit the parents in working through their feelings. Enabling Basic concepts of family centered care are enabling and empowering .in the process of enabling,all the family members are helped by professionals,to create opppourtinities and means to utilize their present abilities,competence and acquire new skills that are necessary to provide care to their ailing children. For eg:family members may be capable of comforting a crying child.This can be entrusted to family members instead of the nurses taking care of this resposibility .However they may not know,how to feed through tube to a baby who require nutritional supplement.This can be taught by nurse,to the competant family members and help them to acquire the skill. Empowering Empowering helps to foster the strength of family members to cope up and withstand stress related to sickness of their children . In family centered care ,the nurses need to move farther from decribing what is upsetting to the family members to describe intervention that are helpful and providing the same to the receipients of care. Nurses should help families to make responsible decisions through education .nurses need to act as an interpreter and develop a mutually respectful and trusting relationship with parents .recognising parents as unique autonomous individuals by creating humanistic empowered environment is the responsibility of nurses in family centered care.This promotes parents support and makes parents capable for providing vital elements of care to their children .Nurses must remember that the nursing care provided will be the same but customer changes.family centerd care expects the nurses should be capable to provide human care that incorporate hopes ,dreams,values,cultural preferences and concerns of children and their parents that are invidualistic in nature. High technology care

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Advancements in medical field has created the care of children to technologically versatile.The nurse also needs to be technogically competent enough to meet the nursing care needs of children .advancements in the diagnostic technology has made detection of many disorders even in the fetal period .High technology induced ethical dilemmas includes controversial fetal surgeries ,fetal blood tranfusions ,medical termination of pregnancy ,cloning ,in vitro fertilisation ,female fetocide etc.Here the nurse needs to be technically competent and must posses soft skills to cope up with techinical advancements. Evidence based practice In evidence based practice nurses need to make decisions on the best avaliable evidence .evidence based practice provides a systemic approach to enable nurses to effectively use the best solution related to nursing practice.hence the nurses needs to search literature to analyse evidences based practice as it involves the ability to accept summarise and apply information from literature day to day clinical problems. Evidence based practice can applied to any problem that seeks solution .The problem seeking solution need to be framed as a question

Frame question

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search evidence -assess for approve evidence--Make decision --evaluate performance .

Atraumatic care A provision of therapeutic care in settings by personal and with intervention that eliminate or minimizes the psychological and physical distress experienced ny children and their families in the health care system.concepts of atraumatic care is to decrease the mental and physical harm and to provide an environment with minimum physical and mental trauma.there are 3 principles to be follolwed in the provision of atraumatic care. 1. prevent or minimise the childs separation from family 2. promote the sense of comfort.

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3. prevent or minimise bodily injury and pain. Suggested nursing intervention are as follows. 1. Foster parent child relationship during hospitalisation. 2. Prepare the child before procedure 3. Control pain 4. Provide child privacy 5. Provide play for expression of fear and agression 6. Minimise loss of control 7. Respect cultural and religion differences especially in the indian setup. Cost cotainment It is a management technique ,utilised to reduce the cost of hospitalisation.this is achieved by many ways in hospital ,either by cutting nursing position or by improving the pricess of care and tightening non labour resources.by decreasing moratality rate ,length of stay ,cost and complication and by increasing family satisfaction and readiness and ability to function upon discharge.nurses may significant contribution to both quality and hospital services and containment of the nursing cost.