1

Basic Science-SPM
S.No Topic Page
1 Case control study 2
2 Confidence interval and p value in medical research 3
3 Systematic review in research 5
4 Sampling technique in clinical research. P IV Dec 2024 7
5 Screening test and validity 8
6 Randomized controlled trial (RCT) 10
7 Odds Ratio 12
8 Outline the goals, strategies and plan of action of Poshan Abhiyan P II Dec 2024 13
9 Nutrition rehabilitation centers (NRC) 14
10 Ayushman Bharat Pradhan mantri Jan arogya yojana (PM-JAY) 16
11 Navajaat shishu Suraksha karyakram (NSSK) P IV Dec 2024 17
12 Discuss the goals, strategies and plan of action for intensified mission of Indradhanush-5 P IV Dec 18
2024
13 District early intervention centre (DEIC) 19
14 RKSK (Rastriya kishor swasthya karyakram) 20
15 TAEI- Tamilnadu accident and emergency care initiative 22
16 Cochlear implant 23
17 Screen time in children 24
18 Sexual abuse in children 25
19 Infanticide 27
20 Delivery point screening 28
21 Mus Quan initiative 28
22 Adolescent friendly health services: 29
23 National mental health program 31
24 Developmental assessment scale for Indian infants (DASII) 32
25 National sickle cell anemia mission 33
26 Suicide prevention 34
27 Adolescent problems 35
28 POCSO act 37
29 Poshan Abhiyan 38
30 Nutrition rehabilitation centers (NRC) 40
31 Sleep hygiene 42
32 Millennium developmental goal focused on children 42
33 Indian newborn action plan 43
34 Human milk banking 46
35 National iodine deficiency control programme 47
36 Trivandrum development scale 48
37 Prenatal genetic testing 49
38 Infant and young child feeding (IYCF) 51
39 Hidden hunger 52
40 Screening test and validity 53
41 Emergency contraception 55
42 Approach to hearing impairment 57
43 Stuttering 58
44 Truancy 59
45 TAEI- Tamilnadu accident and emergency care initiative 60
46 Cochlear implant 61
47 Prevention of diarrheal disease 62
48 Current strategies for polio eradication in India 63
49 Role of paediatrician in adoption of child 64
50 SABLA programme (Rajiv Gandhi scheme for empowerment of adolescent girls) 66
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Case control study

Introduction
1. case control study as an observational epidemiological study of persons with the disease of interest
and a suitable control group of persons without the disease.
2. Case control studies are used to identify factors that may contribute toa medical condition by
comparing subjects who have that condition (the cases) with patients who do not have the condition
but are otherwise similar (controls)
Purpose of Case Control Studies
1. To determine whether or not an association exists between a disease and a particular risk factor.
2. To start with a group of people with disease and work back to see whether a possible risk factor may
be the cause.
3. It may be the first step in testing ahypothesis. If positive, it can then be tested in a cohort study.
There are four basic steps in a case control study:
1. Selection of case and control
2. Matching
3. Measurement of Exposure
4. Analysis
Selection of cases
All the people of the source population who suffer from or develop the disease of interest are included
as cases. It involves two specifications:
1. Diagnostic criteria of the disease and the stage of disease, if any to be included in the study must be
specified before the study is undertaken. Once the diagnostic criteria are established, they should
not be altered or changed till the study is over.
2. Eligibility criteria: The second criterion is that of eligibility. A criterion customarily employed is the
requirement that only newly diagnosed (incident) cases within a specified period of time are eligible
than old cases or cases in advanced stages of the disease (prevalent cases).
3. The cases may be drawn from hospitals or general population.
Selection of control
1. They must be as similar to the cases as possible, except for the absence of the disease under study.
2. The possible sources from which controls may be selected include hospitals, relatives, neighbours
and general population
Matching
Matching is defined as the process by which we select controls in such a way that they are similar to
cases with regard to certain pertinent selected variables (eg : age) which are known to influence the
outcome of disease and which, if not adequately matched comparability, could distort or confound
the results.
Measurement of Exposure
1. Information about exposure should be obtained in precisely the same manner both for cases and
controls.
2. The question of “bias‟ or systematic error must be ruled out.
Analysis
1. The final step is analysis, to find out:
a. Exposure rates among cases and controls to suspected factor.
b. Estimation of disease risk associated with exposure (odds ratio).
c. A case control study provides a direct estimation of the exposure rates (frequency of
exposure) to a suspected factor in disease and non-disease groups.
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2. The second analytical step is estimation of disease risk associated with exposure.
a. From a case control study, we can derive what is known as Odds Ratio (OR) which is a
measure of the strength of the association between risk factor and outcome.
Types of case control studies
1. Nested case-control studies:
a. The population within which the study is conducted is a fully enumerated cohort, which
allows formal random sampling of cases and controls to be carried out.
b. For example, when there is a population-based disease registry and a census enumeration of
the population served by the registry, it may be possible to use the census data to sample
controls randomly.
2. The case cohort study is a case control study in which the source population is a cohort and every
person in this cohort ha an equal chance of being included in the study as a control.
3. Density case control study is based on density sampling. It means, cases are sampled only from
incident cases over a specific time period and controls are sampled throughout that period (rather
than simply at one point in time, such as the end of the period).
4. Case control studies with prevalent cases: Case control studies are sometimes based on prevalent
cases rather than incident cases.
Bias in case control studies is:
1. Bias due to confounding variables.
2. Memory or recall bias
3. Selection bias
4. Interviewers bias
Advantages
1. Relatively easy to carry out:
2. Rapid and inexpensive, can be carried out in shorter duration as compared to cohort studies.
3. Require comparatively few subjects.
Disadvantages
1. Problems of bias relies on memory on past records, the accuracy of which may be uncertain.
2. Selection of an appropriate control group may be difficult.
3. Not suited to the evaluation of therapy or prophylaxis of disease.

Confidence interval and p value in medical research

When we conduct research studies, we are interested in the association between an exposure and a health
outcome. If we plan to involve the whole population in this study, it is practically impossible. So we select a
representative sample from the population for the study. we intend to use the sample mean or proportion
to estimate the population mean or proportion. We hope that the samples statistics will produce results that
portray the truth in the general population.
But the results may be any of the following:
1. By chance.
2. Subject to bias or error.
3. Affected by confounding.
4. The truth.
Different people in the population have varying characteristics. The variations in the different samples in this
same population is just by chance. This is known as random sampling error. The estimate has some
uncertainty because the sample statistic cannot produce the exact population parameter. The conclusions
we invariably draw from these estimates are based on probability. Confidence intervals and p-values help us
to determine whether we have a true result or result due to chance.
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Bias occurs where there are any systematic errors resulting from the way the study was designed, executed
or interpreted.
Confounding refers to a mixing of effects that can occur when the relationship we are interested in is
confused by the effect of something else. Eg. The relation we try to estimate between alcohol and lung
cancer is confounded by smoking and thus not real.
In an attempt to get the truth about the population as close as possible, the sample statistic is subjected to
inferential analysis.
So, the p values and the confidence aid determine the statistical significance of these estimates
P value:
Introduction:
In clinical research, we are interested in the clinical significance of research findings. We derive
clinical significance from statistical significance of data analysis. Statistical significance results are
inferred from p values and confidence intervals.
Null Hypothesis:
The research question is stated in terms of statistical hypotheses. The null hypothesis is a statement
claiming that there is no difference between the assumed value and the population mean. The
alternative hypothesis is a statement that disagrees with the null hypothesis. If the null hypothesis is
rejected as a result of sample evidence, then the alternative hypothesis is concluded.
P value:
1. A p value is used in hypothesis testing to support or reject the null hypothesis. The smaller the p-
value, the stronger the evidence that you should reject the null hypothesis.
2. P values are expressed as decimals and also a percentage. For example, a p value of 0.0254 is 2.54%.
This means there is a 2.54% chance the results could be random (i.e. happened by chance). On the
other hand, a large p-value of 0.9 (90%) means your results have a 90% probability of being
completely random and not due to anything in the experiment. Therefore, the smaller the p-value,
the more important (“significant“) are the results.
3. Graphically, the p value is the area in the tail of a probability distribution.

4. P Value vs Alpha level

a. Alpha levels are related to confidence levels. We get an alpha level by subtracting the
confidence level from 100%. For example, if we want to be 98 percent confident in your
research, the alpha level would be 2% (100% – 98%).
b. When we run the hypothesis test, the test will give a value for p. For an alpha level of 5%
(0.05), a small p (≤ 0.05), the null hypothesis will be rejected. A large p (> 0.05) means the
alternate hypothesis is weak, so you do not reject the null.
5. Significant p-values
a. If p > .10 → “not significant”
b. If p ≤ .10 → “marginally significant”
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c. If p ≤ .05 → “significant”
d. If p ≤ .01 → “highly significant.”
Confidence interval:
1. A confidence interval states how much uncertainty there is with any particular statistic. Confidence
intervals are often used with a margin of error. The specified probability is called confidence level
(95%, 99%). The lower and upper limits of the intervals are called confidence limits.
2. Confidence levels are expressed as a percentage (for example, a 95% confidence level). The size of
the confidence interval is influenced by the selected level of confidence. A 99% confidence interval is
wider than a 95% confidence interval. The wider 99% confidence interval has a higher probability to
cover the true population value.
3. The extra information from confidence intervals when compared to p - value is size of the effect and
the largest and smallest effect sizes (confidence limits)
4. Confidence is another way to describe probability. For example, if we construct a confidence interval
with a 95% confidence level, we are confident that 95 out of 100 times the estimate will fall between
the upper and lower values specified by the confidence interval.
5. The desired confidence level is usually one minus the alpha (α) value you used in the statistical test:

Confidence level = 1 − a

6. So if we use an alpha value of p < 0.05 for statistical significance, then our confidence level would be
1 − 0.05 = 0.95, or 95%.

Systematic review in research

Introduction:
1. History: In 2008, Dr. Robert Boyle and his colleagues published a systematic review in the Cochrane
Database of Systematic Reviews. They answered the question “What is the effectiveness of probiotics
in reducing eczema symptoms and improving quality of life in patients with eczema?” They used
systematic methods to find, select, and synthesize all available evidence, and they described these
methods in detail in their article. For the first time they introduced systematic review for a research
question.
2. A systematic review is a form of analysis that medical researchers carry out to synthesize all the
available evidence on a particular research question.
3. It is a process of searching, gathering and investigating the literature on a specific topic to identify,
select and analyse any evidence of interest. In the past, narrative reviews were used to assess
evidence and was conducted in some informal, unsystematic and subjective ways. Since the narrative
reviews are conducted by individuals there is a very high chance of personal bias.
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4. A meta-analysis is a type of systematic review. Instead of basing conclusions on a single study, a

meta-analysis looks at numerous studies for the answer. A meta-analysis can also form part of a
further systematic review.
5. The Cochrane Collaboration and the Campbell Collaboration are two organizations which oversee the
conducting of systematic reviews based on specific guidelines. The Cochrane Collaboration focuses
on the health sciences, while the Campbell Collaboration works in the areas of crime and justice,
education, international development, and social welfare.
Initial steps in Systematic Reviews
1. Formation of a research team from all relevant areas covering the study topic is the first step.
2. In addition to this team, there may be an advisory group.
3. Third step is to engage with stakeholders who may be involved in implementing the
recommendations.
4. Next is extensive and comprehensive search of all literature relevant to the research question.
The process of systematic review:
Step 1: Formulate a research question
Formulating the research question is the most important step of a systematic review. A research
question has five components, which can be remembered with the acronym PICOT:
a. Population or problem
b. Intervention
c. Comparison
d. Outcome
e. Type of study design
Example: Their research question was:
What is the effectiveness of probiotics versus no treatment, a placebo, or a non-probiotic treatment
for reducing eczema symptoms and improving quality of life in patients with eczema?
a. The population of patients with eczema
b. The intervention of probiotics
c. In comparison to no treatment, placebo, or non-probiotic treatment
d. The outcome of changes in participant-, parent-, and doctor-rated symptoms of eczema and
quality of life
e. Randomized control trials, a type of study design
Step 2: Develop a protocol
A protocol is a document that contains the research plan for the systematic review. This is an
important step because having a plan allows to work more efficiently and reduces bias. protocol
should include the following components:
a. Background information: Provide the context of the research question, including why it’s
important.
b. Research objective(s): Rephrase your research question as an objective.
c. Proposed methods
d. Selection criteria: State how you’ll decide which studies to include or exclude from your
review.
e. Search strategy: Discuss your plan for finding studies.
f. Analysis: Explain what information you’ll collect from the studies and how you’ll synthesize
the data.
Step 3: Search for all relevant studies
Searching for relevant studies is the most time-consuming step of a systematic review. To reduce
bias, it’s important to search for relevant studies very thoroughly.
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Step 4: Apply the selection criteria

After an extensive search for research studies, decide which papers to include and exclude based on
criteria that have come out of your research question.
Step 5: Extract the data
Extracting the data means collecting information from the selected studies in a systematic way. The
research question will guide the types of data you will want to extract from the included studies.
Step 6: Synthesize the data
Synthesizing the data means bringing together all the information that were collected into a single,
cohesive story.
Step 7: Write and publish a report
The article should include the following sections:
a. Abstract: A summary of the review
b. Introduction: Including the rationale and objectives
c. Methods: Including the selection criteria, search method, data extraction method, and
synthesis method
d. Results: Including results of the search and selection process, study characteristics, risk of
bias in the studies, and synthesis results
e. Discussion: Including interpretation of the results and limitations of the review
f. Conclusion: The answer to your research question and implications for practice, policy, or
research
Sampling technique in clinical research.
Sampling
When a large proportion of individuals or items or units have to be studied, we take a sample. It is
easier and more economical to study the sample than the whole population or universe. It is
important to ensure that the group of people or items included in the sample are representative of
the whole population to be studied.
The Sampling frame
Once the universe has been defined, a sampling frame must be prepared. A sampling frame is a
listing of the members of the universe from which the sample is to be drawn.
Probability Sampling (Random) Methods
Simple random sample:
This is done by assigning a number to each of the units (the individuals or households) in the
sampling frame. A table of random numbers is then used to determine which units are to be
included in the sample. Random numbers are a haphazard collection of certain numbers, arranged a
cunning manner to eliminate personal selection of unconscious bias in taking out the sample.
Systematic random sample:
This is done by picking every 5th or 10th unit at regular intervals. By this method, each unit in the
sampling frame would have the same chance of being selected, but the number of possible samples
is greatly reduced.
Stratified random sample:
In this method, the population is divided into homogeneous sub-groups and simple random sampling
is drawn from each sub-group. The sample is deliberately drawn in a systematic way so that each
portion of the sample represents a corresponding stratum of the universe. This method is
particularly useful where one is interested in analysing the data by a certain characteristic of the
population, viz. Hindus, Christians, Muslims, age-groups etc. as we know these groups are not
equally distributed in the population.
Multistage Sampling
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As the name implies this method consists of sampling procedure carried out in several stages, using
random sampling techniques. Example for hookworm survey in a district, 10 percent of talukas are
chosen, followed by 10 percent of villages. Then all persons in 10th house is subjected for stool
examination.
Cluster Sampling
In this case the sampling units are not individuals but clusters such as families in a village, villages in a
district, schools and wards of a city, etc. A sample of clusters proportionate to their size is randomly
drawn. Cluster sampling is employed for carrying out evaluation survey of immunization coverage.
Non-probability Sampling (non-Random) Methods
Convenience sampling:
It is a method in which for convenience’s sake the study units that happen to be available at the time
of data collection are selected in the sample. When there seems no other choice (no one else
available for an interview) researchers may also sample conveniently.
Purposive Sampling
This method is used when focusing on a limited number of informants, whom we select purposively
so that their in-depth information will give optimal insight into an issue about which little is known.
Quota sampling:
This is a stratified random sampling minus randomization. For example, suppose, in a town, there are
50 percent farmers, 25 percent small businessmen and 25 percent workers and a sample of this has
to be drawn, that sample should have the same percentages of these groups. But randomization is
not done.
Screening test and validity
Introduction
Screening is defined as a search made for detecting the hidden disease among apparently healthy
individuals in the community, by means of rapidly applied test. Thus, screening test divides the
apparently healthy population into two groups—those probably having the disease/risk factor and
those probably not having the disease / risk factor.
Types of Screening
1) Mass screening,
2) High-risk screening,
3) Multipurpose screening,
4) Multiphasic screening and
5) Opportunistic screening.
Mass Screening
This is the screening of the entire population of an area for a disease, for example, night blood smear
examination for microfilariae of every individual in hyperendemic area of filariasis. However, this is
not an useful preventive measure unless it is backed up by the treatment and follow-up.
High-risk Screening
This is the screening of only those groups of population, who are at a high-risk of the disease and not
of the entire population. This is also called ‘Selective screening or Targeted screening’. For example,
screening of women of low socioeconomic class for CaCx, of all obese people for hypertension or
diabetes, of sex-workers for HIV, of family contacts of infectious pulmonary tuberculosis or
lepromatous leprosy, etc.
Multipurpose Screening
This is the screening of a group of population by application of two or more tests, at one time to
detect more number of diseases. For example, screening of pregnant mothers with blood for Hb
percent, VDRL, Elisa for HIV, surface antigen for HBV, for blood grouping and Rh-typing, urine for
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albumin, sugar and microscopy; screening all school children with height and weight, vision defects,
hearing defects, dental defects, congenital defects; screening of all elderly persons for diabetes,
hypertension, hearing defects, cancer, cataract, refractive error, glaucoma, etc.
Multiphasic Screening
This is the screening of the population by applying different tests in different phases, for the
diagnosis of one disease. For example, the whole population of an area is screened by testing urine
for sugar. Those who are positive for glycosuria are subjected for fasting blood sugar level (FBS).
Those who have FBS > 120 mg/dL are subjected for oral glucose tolerance test (OGTT) to find out
true diabetics.
Opportunistic Screening
This is the screening of a patient, who consults the doctor for some other purpose. This is also called
‘Case finding screening’.
Validity of screening
1) Validity of a test means the ability of a test to correctly identify those with disease from those
without the disease among the apparently healthy people. For example, oral glucose tolerance test is
a more accurate (valid) test than examining urine for sugar. Similarly, Treponema pallidum
immobilization test is more valid than blood for VDRL test.
2) Validity has got two components—sensitivity and specificity; both the components can be
determined by applying the screening test on two groups of persons, one group having the disease
and another group not having the disease and expressed as percentages.
3) The relationship between a screening test result and the occurrence of disease is interpreted as
follows:
Interpretation
1) True positive (a) = Means those who have the disease and the test result is also positive.
2) False positive (b) = Means those who do not have the disease but the test result is positive.
3) False negative (c) = Means those who have the disease but the test result is negative.
4) True negative (d) = Means those who do not have the disease and the test result is also negative.
Evaluation of a screening test for the validity (Expressed in percentages).
The following indicators are used to evaluate the screening test:
Sensitivity:
1. It is the ability of a test to correctly identify those having the disease, i.e. true positives. (i.e.
percentage of diseased persons, showing the test result positive).
Sensitivity = a ×100
a+ c
2. Sensitivity of a screening test is 90 percent means, 90 percent of the diseased persons are correctly
identified as ‘True positives’ and remaining 10 percent of diseased persons are wrongly identified as
not having the disease, because the test is negative (False negatives).
Specificity:
1. If is the ability of the test to correctly identify those not having the disease, i.e. true negatives. (i.e.
percentage of non-diseased persons, showing the test result negative)
Specificity = d ×100 .
b+d
2. Predictive value of a test: It means the diagnostic power of a test. The test has 2 results, positive and
negative.
a. Predictive value of a positive test: It means the probability of an individual really having the
disease, if the test result is positive. (i.e. percentage of positives probably having the
disease.
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Predictive value of a positive test = a × 100.

a+b
b. Predicted value of a negative test: It means the probability of an individual really not having
the disease, if the test result is negative. (i.e. percentage of negatives probably not having
the disease)
Predicted value of a negative test = d × 100.
c+d
3. False positives: These are the percentage of non-diseased persons wrongly identified as having the
disease, because the test result is positive.
False positives = b × 100
b+d
4. False negatives: These are the percentage of diseased persons wrongly identified as not having the
disease, because the test result is negative.
False negatives = c × 100.
a+c
Example
A new screening for a certain disease was administered to 480 persons, 60 of whom are known to
have the disease. The test was positive in 50 of the persons with the disease as well as in 20 persons
without the disease. Evaluate the screening test by all the measures.
1. Sensitivity (True positive) = a/a+c × 100 = 50/60 × 100 = 83.33%.
2. Specificity (True negative) = d/b+d × 100 = 400/420 × 100 = 95.24%.
3. Predictive value of a positive test = a/a+b × 100 = 50/70 × 100 = 71.43%.

Randomized controlled trial (RCT)

Introduction
Randomized controlled trial (RCT) is so called because the patients who constitute the unit of study
are allocated into ‘Study group’ (experimental group) and ‘Control group’ at random, depending
upon whether they receive or do not receive the intervention. Random allocation eliminates bias.
Aim: is to test the efficacy of a new drug or a new drug regimen or a new therapeutic or surgical procedure.
Basic steps: In conducting a clinical trial (RCT) are:
1. Drawing of a protocol.
2. Selecting reference population (unit of study).
3. Randomization (Allocation into experimental and control group).
4. Manipulation (intervention).
5. Follow-up.
6. Assessment of outcome.
7. Reporting.
Drawing of Protocol
This means specifying the following basic information before the commencement of the clinical trial.
They are:
1. Aims and objectives of the study.
2. Criteria for the selection of study group and control group.
3. Size of the sample.
4. Procedures for allocation into study group and control group.
5. Intervention to be done (Methodology of procedure).
6. The cooperation of the participants till the end of the study.
Selection of Reference Population
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Reference population is the target population, to which the results if found successful, are expected
to be applicable. Reference population, depending upon the study, could be all suffering from a
particular disease under experiment, e.g. TB/leprosy patients for new therapy/new regimen or
patients with hernia for new surgical procedure, etc.
Randomization
1. Randomization eliminates bias and allows comparability.
2. Study group (Experimental group): It is the actual population derived from the reference population
randomly.
3. Control group: Another group of the same size as that of the study group is selected at random from
the reference population, maintaining the similar characteristics
Manipulation or Intervention
The next step is to intervene or manipulate the study group by the application the causal factor, i.e.
new drug, whereas the control group is put on the placebo.
Follow-up
This consists of examination of both the groups at defined intervals of time for the time framed and
the results are submitted to the statistician.
Assessment of Outcome
This is the final step of clinical trial. The results may be positive (e.g. the new drug is better and safer)
or may be negative (e.g. the new drug is not good and/or more hazardous). The incidence of results
(positive or negative) is compared in both the groups and the differences are tested for the tests of
significance.
Bias
Bias may arise from three sources resulting in errors, as follows:
1. Subject variation: Patients may report better/improvement, if they know that they are under
new treatment.
2. Observer bias: Is made by the investigator while observing.
3. Bias in evaluation: Is made by the investigator subconsciously.
Blinding
In order to overcome these errors and bias, a technique known as ‘Blinding’ is adopted, which is
done in three ways.
1. Single blind trial: When only study participants are unaware of their treatment status, but
investigators and analysts are aware of treatment status, the trial is called single-blinded.
2. Double blind trial: When both the participants and the investigators are blinded as to the
treatment status of the participants the trial is termed double-blinded.
3. Triple blind trial: A triple-blinded trial is when subjects, investigators, and independent
statisticians are kept unaware of subject treatment status.
Phases of clinical trials:
Clinical trials are conducted under the following phases:
1. Phase I: Trial is done on a small group of healthy individuals to (10 to 30) know the safety, the
efficacy and the side effects of the vaccine. Usually, it takes 8 to 12 months to complete phase I trial.
2. Phase II: Trial is carried out on a larger group of persons (50-500), to know not only the safety of the
vaccine but also refining the dosage schedule. This is often carried out in multiple centers. Phase II
trials generally take 18 to 24 months to complete. In Phase II b trails (Step study or test of concept
trial) enables the researcher to decide whether the vaccine is worth testing in larger.
3. Phase III trial: In this phase, trial is carried out on thousands of volunteers not only to know the
safety, efficacy and immune response but also to decide whether the vaccine is fit for manufacturing.
The minimum duration of phase III trial is up to three years
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4. Phase IV: This is a continuous ongoing process to know the long- term effects of the vaccine.
Types of study designs
1. Concurrent parallel study design: From the reference population, patients are drawn randomly and
allocated into and control group and they would remain in the same group for the duration of the
experiment.
2. Double blind cross-over study design: As before, the patients are randomly allocated into study
group and control group and respectively put on new drug and old drug. Half way through the study,
the drugs are withdrawn for the elimination of drugs from the body. Afterwards, the groups are
interchanged, i.e. the study group is now put on old drug and the control group on the new drug.
Suppose, those who were on the new drug initially showed good recovery and then failed to do so
after changeover (cross-over) in the latter half of the study period, the new drug is regarded as a
really effective one.
3. Co-operative (Multicentric) trial: This is a clinical trial jointly planned and simultaneously carried out
in different parts of the country or in different countries.
Reporting
A detail report of the trial is written and sent to a medical journal for publication.

Odds Ratio
ODDS:
Chance of event occurring divided by chance of event not occurring. For example, in 100 births, the
probability of a delivery being a boy is 51% and being a girl is 49%. The odds of a delivery being a boy is
51/49 = 1.04. In simpler term, an odds of an event can be calculated as: Number of events divided by
number of non-events.
ODDS RATIO
1. An odds ratio is the odds of the event in one group, for example, those exposed to a drug, divided
by the odds of the event in another group not exposed
2. Odd ratio in epidemiology:
In case control study since the incidence is not available so relative risk cannot be calculated
directly. Therefore, Odd ratio is obtained which is a measure of strength of association
between exposure and outcome
Odd ratio in case control study

Case control

Exposed a b

unexposed c d
Odd of exposure among the cases: a/c
Odd of exposure among the control: b/d
Therefore, Exposure odd ratio is: a/c ÷ b/d = ad/bc
Interpretation of odds ratio (OR):
1. OR of >1 indicates that the exposure is associated with an increased risk of developing the disease.
2. OR of <1 indicates that the exposure is associated with the reduced risk of (protect against)
developing the outcome.
3. Closer the value of OR to 0 greater the protection.

Outline the goals, strategies and plan of action of Poshan Abhiyan P II Dec 2024
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Introduction
Government of India has launched “Poshan Abhiyan” on 18th December 2017 for a period of three years
commencing from 2017-18, in all 36 states/UTs. The goals are to achieve improvement in nutritional
status of children from 0-6 years, adolescent girls, pregnant women and lactating mothers with fixed
targets.
Background
1. POSHAN Abhiyaan aims to reduce malnutrition, through a life-cycle concept, adopting a synergised
and result-oriented approach. Implemented by the Ministry of Women and Child Development
(MWCD), Government of India, the target of the mission is to bring down stunting in children 0-6
years of age from 38.4% to 25% by 2022.
2. It also aims to reduce anaemia among women and adolescent girls in the age group of 15-49 years
and reduce low birth weight.
3. The POSHAN Abhiyaan intends to achieve its goals by focusing on:
a. mobile-based information technology tools for improved service delivery and monitoring.
b. multi-sectoral planning and monitoring actions from the state to block level for improved
nutrition outcomes;
c. capacity building of Integrated Child Development Services (ICDS) functionaries on nutrition
counselling of pregnant women and mothers of children up to two years of age;
d. community mobilisation and behaviour change communication; and
e. providing performance-based incentives for community nutrition and health workers, and
states.
4. It ensures convergence of various programmes i.e. anganwadi services, Pradhan Mantri Matru
Vandana Yojana; schemes for adolescent girls of Ministry of Women and Child Development; Janani
Suraksha Yojana; National Health Mission of Ministry of Health and Family Welfare; Swachh Bharat
Mission of Ministry of Jal Shakti etc.
5. The objectives and targets are as follows:
a. Prevent and reduce stunting in children (O—6 years) By 6 per cent (2 per cent/ year)
b. Prevent and reduce under nutrition and underweight prevalence in children (0-6 years) By 6
per cent (2 per cent/ year)
c. Reduce the prevalence of anaemia By 9 per cent (3 per cent/ year) among children (6-59
months)
d. Reduce the prevalence of anaemia among girls and women in the age group (15-49 years) By
9 per cent (3 per cent/ year)
e. Reduce low birth weight (LBW) By 6 per cent (2 per cent/ year)
6. The Abhiyan aims to reduce malnutrition in the country through a life cycle approach.
7. Anganwadi Centres are equipped with Smart phones and Growth Monitoring devices (GMDs) such as
Infantometer, Stadiometer, Weighing Scale for Mother and Infant.
5 Pillars of POSHAN Abhiyaan National Nutrition Mission

5 Pillars of POSHAN Abhiyaan

Pillar Poshan Abhiyaan ICDS-Common • With the software, the nutritional status will be
1 Application Software (CAS) monitored.
• Workers for AWWs and Supervisors will receive a
smart phone.
• To measure the growth of the infant, mother, and
kid, AWWs and Supervisors will be given growth
 14

monitoring tools such a stadiometer,

infantometer, and weighing scales.
Pillar Convergence Action Planning • It aims to ensure the convergence of all nutrition-
2 related schemes on the target population.
Pillar Capacity Building of Poshan Abhiyaan ICDS • Anganwadi workers are participating in a capacity-
3 officials/functionaries through the building & learning programs by participating in
Incremental Learning Approach (ILA) existing supervisor meetings.
• The incremental Learning Approach includes 21
thematic modules for AWWs and Supervisors.
Pillar Jan Andolan (Behaviour Change • The Abhiyaan will be managed as a Jan Andolan
4 Communication and Community with desired public involvement.
Mobilisation) • A community-based event will be held once a
month to raise awareness and address issues.
Pillar Performance Incentives • Capacity building should be planned alongside
5 improved service delivery.
• Front-line workers will be given incentives for
their efforts.

Nutrition rehabilitation centers (NRC)

1. Severe acute malnutrition is an important contributing actor for most deaths among children suffering
from common childhood illness such as diarrhoea and pneumonia. Deaths among these malnourished
children are preventable, provided timely and appropriate actions are taken. NRCs are facility based units
providing medical and nutritional care to Severe Acute Malnutrition (SAM) children under 5 years of age
who have medical complications. In addition special focus is on improving the skill of mothers on child
care and feeding practices so that the child continues to get adequate care at home.
2. The services provided at the NRCs include:
a. 24 hours care and monitoring of the child;
b. Treatment of medical complication;
c. Therapeutic feeding;
d. Sensory stimulation and emotional care; e. Counselling on appropriate feed, care and hygiene;
e. Demonstration and practice-by-doing on the preparation of energy dense food using locally
available, culturally acceptable and affordable food items;
f. Social assessment of the family to identify and address contributory factors; and
g. Follow up of the children discharged from the facility.
Management of medical complications in a child with SAM at health facility
1. Triage is the process of rapidly screening sick children. Triage must be done for all paediatric patients
coming to the health facility. The first step is to check every child for emergency signs and provide
emergency treatment as necessary, keeping in mind the ABCD steps: Airway, Breathing, Circulation,
Coma, Convulsion and Dehydration.
2. Assessment at admission: The child should be assessed by taking detailed history and should be
examined for the signs of under-nutrition.
Principles of hospital-based management:
1. The principles of management of SAM are based on 3 phases: stabilization phase, transition phase
and rehabilitative phase.
3. Stabilization Phase: Children with SAM without an adequate appetite and/or a major medical
complication are stabilized in an in-patient facility. This phase usually lasts for 1-2 days. The feeding
 15

formula used during this phase is Starter diet which promotes recovery of normal metabolic function
and nutrition - electrolytic balance. All children must be carefully monitored for signs of overfeeding
or over hydration in this phase.
4. Transition Phase: This phase is the subsequent part of the stabilization phase and usually lasts for 2-3
days. The transition phase is intended to ensure that the child is clinically stable and can tolerate an
increased energy and protein intake. The child moves to the Transition Phase from Stabilization
Phase when there is:
i. Atleast the beginning of loss of oedema.
ii. Return of appetite.
iii. No nasogastric tube, infusions, no severe medical problems.
iv. Is alert and active
The ONLY difference in management of the child in transition phase is the change in type of diet.
There is gradual transition from starter diet to catch up diet. The quantity of catch up diet given is
equal to the quantity of starter diet given in stabilization phase.
5. Rehabilitation Phase: Once children with SAM have recovered their appetite and received treatment
for medical complications they enter Rehabilitation Phase. The aim is to promote rapid weight gain,
stimulate emotional and physical development and prepare the child for normal feeding at home.
The child progresses from transition phase to rehabilitation phase when:
a. S/he has reasonable appetite; finishes > 90% of the feed that is given, without a significant
pause.
b. Major reduction or loss of oedema.
c. No other medical problem.
The ONLY difference in management of the child in transition phase is the change in type of diet.
There is gradual transition from starter diet to catch up diet. The quantity of catch up diet given is
equal to the quantity of starter diet given in stabilization phase.
Micronutrient supplementation
1. Vitamin A: Give Vitamin A in a single dose to all SAM children unless there is evidence that child has
received vitamin A dose in last 1 month. Recommended oral dose of Vitamin A according to
child’s age:
<6 months — 50,000 IU
6-12 months or if weight <8 kg 100,000 IU
>12 months 200,000 IU
Give same dose on Day 1, 2 and 14 if there is clinical evidence of vitamin A deficiency.
IM treatment should be used in children with severe anorexia, oedematous malnutrition, or septic
shock. Only water based formulations and half of oral dose should be used.
2. Other micronutrients should be given daily for at least 2 weeks:
a. Multivitamin supplement (should contain vitamin A, C, D, E and B,, and not just vitamin B
complex): Twice recommended daily allowance.
b. Folic acid: 5 mg on day 1, then 1 mg/day.
c. Elemental Zinc: 2 mg/kg/day.
d. Copper: 0.3 mg/kg/day (if separate preparation not available use commercial preparation
containing copper).
e. Iron: child Start being daily on iron catch supplementation up diet. Give after elemental two
days of iron the in the dose of 3 mg/kg/day in two divided doses, preferably between meals.
(DO not give iron in stabilization phase).
Follow-up of children discharged from NRC
 16

1. Close collaboration and information sharing between NRC and community based care ( at PHC, sub-
centre and AWC) are essential. The list of SAM children discharged from NRC should be shared with
area specific ANM and ICDS supervisors. These children should be enrolled in the anganwadi centre
and given supplementary food as per the guidelines. The AWWs should prioritize these children for
home visits, every week in the first 4 weeks and then once in 2 weeks till the child is discharged from
the programme.
2. During the home visits, AWW should observe feeding and provide appropriate counselling and
support to the mother.
3. These children should be weighed every week at AWC. The ASHA and AWW should ensure that these
children should return for the scheduled follow-ups at the NRC.
4. Incentive of Rs 50 can be provided to ASHA for accompanying the child to the NRC and motivating
the mother to stay at NRC for atleast 7 days till the child is stabilized and has started to eat.
Additional incentive of Rs 50 may be given for each follow-up visit by the child, upto a maximum of
three visits.
Ayushman Bharat pradhanmantri Jan arogya yojana (PM-JAY)
1. In February 2018, the Govt. of India announced two major initiatives in health sector, with aim to cover
preventive and health promotive interventions at primary, secondary and tertiary care system. They are
as follows:
a. Health and Wellness Centre: The National Health Policy, 2017 has envisioned Health and
Wellness Centers as the foundation of India’s health system. Under this 1.5 lakh centers will bring
health care system closer to homes of people. The health centers will provide comprehensive
health care, including maternal and child health services, Communicable Diseases services, and
services related to Non-Communicable Diseases. To begin with, the common NCDs such as
hypertension, diabetes and 3 common cancers of oral, breast and cervix. It is also envisaged to
incrementally add primary healthcare services for mental health, ENT, opthalmology, oral health,
geriatric and palliative health care and trauma care, as well as health promotion and wellness
activities like Yoga. A few States have already started rolling out these additional packages of
services in a phased manner. The centers will also provide free essential drugs and diagnostic
services.
b. The second component is the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
which provides health coverage upto Rs. 5.00 lakh per family per year to about 10.74 crore poor
and vulnerable families identified on the basis of Socio-Economic Caste Census data.
2. The first Health and Wellness Centre was inaugurated on 14th April 2018 in Bijapur district of
Chhattisgarh. So far, 77,786 centres are operational in the country as on 16th Sep. 2021. Primary
healthcare team at the Sub Health Centre level AB-HWCs is headed by Community Health Officer (CHO)
who is a BSc/GNM Nurse or an Ayurveda Practitioner trained in primary care and public health skills, and
certified in a six months certificate programme in community health. Other members of the team being
multi-purpose workers (Male and Female) and Accredited Social Health Activists (ASHAs).
3. The training programme is being carried out with support from IGNOU and state specific Public/Health
Universities. 282 IGNOU Programme Study Centres (PSCs) have been notified so far, and another 111
PSCs have been notified under the state specific certificate programme in the state of Maharashtra, Tamil
Nadu, Gujarat and West Bengal, taking the total of programme study centres to 393 across the country.
4. Since the screening, prevention and management of chronic illnesses including NCDs, TB and Leprosy
have been introduced at AB-HWCs, training and skill upgradation of the primary health team in all the
functional AB-HWCs on NCDs and use of IT application is being done. To promote wellness and healthy
lifestyle, orientation of the public on wellness activities for lifestyle modification like increased physical
 17

activity (cyclathons and marathons), eating RIGHT and SAFE, cessation of tobacco and drugs, meditation,
laughter clubs, open gyms, etc. is being done.
5. Beside these, Yoga sessions are being conducted at these centres on regular basis. Through annual health
calendar, planned activities at these centres on the health condition of the day are resulting in increased
awareness and preventive measures to be adopted by the public. The telemedicine guidelines have also
been provided to the States to initiate specialist consultations from the PHCs to the Hub Hospitals and
the pilot of the application is being conducted in Andhra Pradesh, Tamil Nadu and Maharashtra.
6. Expanded service packages planned to be provided at functional. AB-HWCs are as follows:
a. Care in pregnancy and child birth.
b. Neonatal and infant health care services.
c. Childhood and adolescent health care services.
d. Family planning, contraceptive services and other reproductive health care services.
e. Management of communicable diseases: Health programmes.
f. General out-patient care for acute simple illnesses and minor ailments.
g. Screening, prevention, control and management of noncommunicable diseases and chronic
communicable diseases like tuberculosis and leprosy.
h. Basic oral health care.
i. Screening and basic management of mental health ailments.
j. Care for common ophthalmic and ENT problem.
k. Elderly and palliative health care services.
l. Emergency medical services including burns and trauma.
National Expected outcome
1. Increasing the trust of people on the service provision by public healthcare facilities through health
system strengthening and improvement.
2. Availability of assured healthcare services to ensure continuum of care.
3. Reduction in out of pocket expenditure of the common people.
4. Increased awareness among the people about preventive and promotive healthcare.
5. Benefits of healthy lifestyle including Yoga, and eat right & eat safe etc.
6. Enabling environment to increase the health seeking behaviour of the poor people.

Navajaat shishu Suraksha karyakram (NSSK)

1. To reduce perinatal asphyxia related morbidity and mortality, Government of India launched a training
programme - Navjaat Shishu Suraksha Karyakram (NSSK) - essential newborn care and resuscitation in
2009-10. The course was aimed to impart the basic skills required to manage common neonatal
problems related to birth asphyxia, infections, hypothermia and breastfeeding.
2. With advances in critical care and based on the evidence, the NSSK training package has now been
revised with updated algorithm and improved training methodology. The revised training package is two
days classroom and hands-on training. Training package includes a resource manual and Flip chart. NSSK
aimed to train all health workers and doctors involved in delivery and newborn care.
3. The training package emphasizes the skill imparting techniques by the facilitators and ensures uniform
messaging across all the levels. This revised training package is an enabling tool and helps healthcare
providers to improve their clinical skills and practices and contribute to newborn survival and health in
the country.
4. The programme was rolled out across most states of India and more than one and a half lakh health
personnel have been trained till now.
5. A resource manual has been developed to assist the facilitators in organizing the NSSK trainings using
the revised package and the participants to use as a reference manual after the training.
 18

6. Methodology of Training
a. Revised NSSK package is a customized 2-days clinical update cum skill standardization training at
identified training sites. (Preferably near SNCU/Newborn Care unit where the participants can be
easily transferred for equipment demonstration)
b. Facilitators: Trained paediatricians, medical officers and nurse tutors who have undergone
master training can facilitate this training. For a batch of 24-28 participants, 4 facilitators shall be
required.
c. Eligibility of participants: All service providers working in the labour room, and involved with care
of mother and the baby at time of birth are eligible for this training. Even SBA trained providers
will be eligible for this training
d. Logistics:
▪ Room with a seating capacity of at least 30-35 people or two separate rooms with a
seating capacity of 15-20 people, each.
▪ The number of tables should be 2 in each room with seats for 2 facilitators and 12 to 14
participants (6 to 7 participants on each table). Each room should have two wall charts of
the ‘resuscitation’ algorithm/List of items for Participant’s Folder (Note Pad, Pen, Name
Tag)
▪ Flipchart, marker or blackboard and chalk
7. Sites of training: In each district, either the district hospital (DH) or/and a high case load sub district
hospital should be the training site. One or more than one (depending on the size/need of the state),
state level TOTs should be organized to develop a resource pool of trainers to continue trainings at the
district level. The trainings should ideally be followed by mentoring visits.

Discuss the goals, strategies and plan of action for intensified mission of Indradhanush-5 P IV Dec 2024
Mission Indradhanush
1. Mission Indradhanush (MI) was launched in December 2014 and aims at increasing the full
immunization coverage to children to 90%. Under this drive focus is given on pockets of low
immunization coverage and hard to reach areas where the proportion of unvaccinated and partially
vaccinated children is highest. A total of six phases of Mission Indradhanush have been completed
covering 554 districts across the country.
2. It was also identified as one of the flagship schemes under Gram Swaraj Abhiyan (16,850 villages
across 541 districts) and Extended Gram Swaraj Abhiyan (48,929 villages across 117 aspirational
districts).
3. While the first two phases of Mission Indradhanush resulted in 6.7% increase in full immunization
coverage in a year, a recent survey carried out in 190 districts covered in Intensified Mission
Indradhanush (5th phase of Mission Indradhanush) shows 18.5% points increase in full immunization
coverage as compared to NFHS-4 survey carried out in 2015-16.
The Intensified Mission Indradhanush 5.0 (IMI 5.0),
1. A routine immunization campaign by the Indian government, aimed to improve vaccination coverage
for all vaccines under the Universal Immunization Programme (UIP), with a special focus on measles
and rubella, and was conducted in three rounds from August to October 2023.
2. Launch Period: August to October 2023.
3. Rounds: Conducted in three rounds with specific days for routine immunization.
4. Focus: Expanded to include children up to 5 years; improved Measles and Rubella vaccination.
5. Platform: Utilized U-WIN digital platform for monitoring.
Vaccination Strategy
 19

1. Mission Indradhanush employs a systematic approach to vaccination, ensuring that all targeted
individuals receive the necessary vaccines. The program emphasizes:
2. Routine Immunization: Ensuring that all children up to 2 years of age and pregnant women receive
the required vaccinations as per the immunization schedule.
3. Catch-Up Campaigns: Identifying and vaccinating individuals who missed their vaccinations during
routine immunization due to various reasons.
4. Regular Monitoring: Tracking immunization coverage and addressing any gaps to improve overall
vaccination rates.
5. The program’s success relies on the effective coordination between various health departments,
community workers, and healthcare providers who work together to ensure that vaccines are
administered efficiently and reach those in need.

District early intervention centre (DEIC)

1. Rashtriya Bal Swasthya Karyakram (RBSK) is an important initiative aiming at early identification and early
intervention for children from birth to 18 years to cover 4 ‘D’s viz. Defects at birth, Deficiencies, Diseases,
Development delays including disability.
2. It is important to note that the 0-6 years age group will be specifically managed at District Early
Intervention Center (DEIC) level while for 6-18 years age group, management of conditions will be done
through existing public health facilities. DEIC will act as referral linkages for both the age groups.
3. First level of screening is done at all delivery points through existing Medical Officers, Staff Nurses and
ANMs. After 48 hours till 6 weeks the screening of newborns will be done by ASHA at home as a part of
Home Based New-born Care (HBNC) package.
4. Outreach screening will be done by dedicated Mobile Health teams for 6 weeks to 6 years at anganwadis
centres and 6-18 years children at school. Once the child is screened and referred from any of these
points of identification, it would be ensured that the necessary treatment/intervention is delivered at
zero cost to the family.
Selected Health Conditions for Child Health Screening & Early Intervention Services
Defects at Birth Deficiencies
1. Neural tube defect 10. Anaemia especially Severe anaemia
2. Down's Syndrome 11. Vitamin A deficiency (Bitot spot)
3. Cleft Lip & Palate / Cleft palate alone 12. Vitamin D Deficiency, (Rickets)
4. Talipes (club foot) 13. Severe Acute Malnutrition
5. Developmental dysplasia of the hip 14. Goiter
6. Congenital cataract
7. Congenital deafness
8. Congenital heart diseases
9. Retinopathy of Prematurity
Diseases of Childhood Developmental delays and Disabilities
15. Skin: (Scabies, fungal infection and Eczema) 21. Vision Impairment
16. Otitis Media 22. Hearing Impairment
17. Rheumatic heart disease 23. Neuro-motor Impairment
18. Reactive airway disease 24. Motor delay
19.Dental conditions 25. Cognitive delay
20. Convulsive disorders 26. Language delay
27. Behavior disorder (Autism)
28. Learning disorder
29. Attention deficit hyperactivity disorder
 20

30. Congenital Hypothyroidism, Sickle cell anemia,

Beta thalassemia (Optional)
Screening at Community & Facility level:
Child screening under RBSK is at two levels community level and facility level. While facility based
new born screening at public health facilities like PHCs / CHCs/ DH, will be by existing health
manpower like Medical Officers, Staff Nurses & ANMs, the community level screening will be
conducted by the Mobile health teams at Anganwadi Centres and Government and Government
aided Schools.
Screening at Anganwadi Centre:
All pre-school children below 6 years of age would be screened by Mobile Block Health teams for
deficiencies, diseases, developmental delays including disability at the Anganwadi centre at least
twice a year. Tool for screening for 0-6 years is supported by pictorial, job aids specifically for
developmental delays. For developmental delays children would be screened using age specific tools
specific and those suspected would be referred to DEIC for further management.
Screening at Schools- Government and Government aided:
School children age 6 to 18 years would be screened by Mobile Health teams for deficiencies,
diseases, developmental delays including disability, adolescent health at the local schools at least
once a year. The tool used is questionnaire (preferably translated to local or regional language) and
clinical examination.
Composition of mobile health team:
The mobile health team will consist of four members - two Doctors (AYUSH) one male and one
female, at least with a bachelor degree from an approved institution, one ANM/Staff Nurse and one
Pharmacist with proficiency in computer for data management.
District Early Intervention Centre (DEIC)
1. The purpose of DEIC is to provide referral support to children detected with health conditions during
health screening, primarily for children up to 6 years of age group.
2. A team consisting of Pediatrician, Medical officer, Staff Nurses, Paramedics will be engaged to
provide services. There is also a provision for engaging a manager who would carry out mapping of
tertiary care facilities in Government institutions for ensuring adequate referral support. The funds
will be provided under NHM for management at the tertiary level at the rates ¬fixed by State
Governments in consultation with Ministry of Health & Family Welfare. Thus, the DEIC will be the
hub of all activities, will act as a clearing house and also provide referral linkages.

RKSK (Rastriya kishor swasthya karyakram)

Introduction
1. The Ministry of Health & Family Welfare has launched a health programme for adolescents, in the
age group of 10-19 years, which would target their nutrition, reproductive health and substance
abuse, among other issues.
2. The Rashtriya Kishor Swasthya Karyakram was launched on 7th January, 2014. The key principle of
this programme is adolescent participation and leadership, Equity and inclusion, Gender Equity and
strategic partnerships with other sectors and stakeholders. The programme envisions enabling all
adolescents in India to realize their full potential by making informed and responsible decisions
related to their health and well-being and by accessing the services and support they need to do so.
3. To guide the implementation of this programme, MOHFW in collaboration with UNFPA has
developed a National Adolescent Health Strategy. It realigns the existing clinic-based curative
approach to focus on a more holistic model based on a continuum of care for adolescent health and
developmental needs.
 21

4. The Rashtriya Kishor Swasthya Karyakram (National Adolescent Health Programme), will
comprehensively address the health needs of the 243 million adolescents. It introduces community-
based interventions through peer educators, and is underpinned by collaborations with other
ministries and state governments.
The Vision
1. The strategy envisions that all adolescents in India are able to realise their full potential by making
informed and responsible decisions related to their health and well-being, and by accessing the
services and support they need to do so. The implementation of this vision requires support from the
government and other institutions, including the health, education and labour sectors as well as
adolescents’ own families and communities.
2. Building an agenda for adolescent health requires an escalation in the visibility of young people and
an understanding of the challenges to their health and development. It needs implementation of
approaches that will ensure a successful transition to adulthood. This requires that the multi-
dimensional health needs and special concerns of adolescents are understood and addressed in
national policies and a range of programmes at different levels.
Objectives
1. Improve nutrition
2. Reduce the prevalence of malnutrition among adolescent girls and boys
3. Reduce the prevalence of iron-deficiency anaemia (IDA) among adolescent girls and boys
4. Improve sexual and reproductive health
5. Improve knowledge, attitudes and behaviour, in relation to SRH
6. Reduce teenage pregnancies
7. Improve birth preparedness, complication readiness and provide early parenting support for
adolescent parents
8. Enhance mental health
9. Address mental health concerns of adolescents
10. Prevent injuries and violence
11. Promote favorable attitudes for preventing injuries and violence (including GBV) among adolescents
12. Prevent substance misuse
13. Increase adolescents’ awareness of the adverse effects and consequences of substance misuse
14. Address NCDs
15. Promote behaviour change in adolescents to prevent NCDs such as hypertension, stroke, cardio-
vascular diseases and diabetes
Target Groups
The new adolescent health (AH) strategy focuses on age groups 10-14 years and 15-19 years with
universal coverage, i.e. males and females; urban and rural; in school and out of school; married and
unmarried; and vulnerable and under-served.
Strategies
Strategies/interventions to achieve objectives can be broadly grouped as:
1. Community based interventions
2. Peer Education (PE)
3. Quarterly Adolescent Health Day (AHD)
4. Weekly Iron and Folic Acid Supplementation Programme (WIFS)
5. Menstrual Hygiene Scheme (MHS)
Facility based interventions
Strengthening of Adolescent Friendly Health Clinics (AFHC)
Convergence
 22

1. Within Health & Family Welfare - FP, MH (incl VHND), RBSK, NACP, National Tobacco Control
Programme, National Mental Health Programme, NCDs and IEC
2. With other departments/schemes - WCD (ICDS, KSY, BSY, SABLA), HRD (AEP, MDM), Youth Affairs and
Sports (Adolescent Empowerment Scheme, National Service Scheme, NYKS, NPYAD)
3. Social and Behaviour Change Communication with focus on Inter Personal Communication.

TAEI- Tamilnadu accident and emergency care initiative

Introduction
TAEI is a government initiative in Tamil Nadu that aims to reduce the number of deaths and illnesses in
the state. TAEI facilities are equipped with advanced infrastructure and efficient staff. The initiative also
includes training for emergency department staff on basic care and primary resuscitation.
Aims:
1. To Initiate and Maintain and Health Care Setup to provide Comprehensive Service to All Medical and
Surgical Emergencies aimed at Reducing the Mortality and Morbidity
2. To Develop and Implement Protocols for Uniform and High Quality Care in Emergency Departments
across All Hospitals
3. To Develop and Implement Protocols for effective Management to Reduce Mortality and Morbidity
associated with Non Communicable Diseases, especially (1) Accidents and Trauma (2) Myocardial
Infarction (3) Cerebro Vascular Accidents (Strokes), (4) Burns (5) Poisoning (6) Paediatric Emergencies
Objectives
1. To halve the number of deaths and injuries from road traffic accidents by the year 2020 globally.
2. To achieve halve the number of deaths (8500) and injuries from road traffic accidents by year 2023 in
Tamil Nadu State.
3. To Standardize Managements of All Medical and Surgical Emergencies into predefined and distinct
stages and to have specific and clear protocols for management in each stage
4. To Triage Patients into Red, yellow and Green Categories and to institute appropriate management
5. To ensure definitive treatment for the injured within the Golden Hour and to have “Time Norms” for
procedures in the Emergency Department
6. To Start the Process of Rehabilitation as early as possible
7. To identify and designate TAEI Centres as Level-1, Level-2, Level-3 centres with Assured Care in Each
Centre based on the level
8. To Augment the Hard (Civil Works, Equipments, Consumables, Drugs) and Soft (Human Resources-
New Posts as well as Filling Vacancies, Training) Infrastructure in these centres as per need and
implementation of Standard Operating Procedures in these centres
9. To install the Basic Life Support Ambulances Level -IV on an evidence based approach along the
Highways and Advanced Life Support Ambulance at Trauma Care Facilities for inter facility transfer
and expand the ECC facilities provided already to all high accident density areas.
10. To initiate the development of a state-wide referral network with both public and private hospitals
through empanelment of CMCHIS Insurance
11. To establish “State Trauma Surveillance Centre” with real time reporting of accident & trauma cases
for the Trauma Registry which will provide evidence based decision for policy formulation on road
safety, injury preventive interventions with component for improving of quality care and better out
comes and rational utilization of resources and Continuous physical & financial monitoring of the
programme.
Expected outcome
(TAEI) is expected to have the following tangible results.
1. Emergency Room uniformly standardized in each facility of the state
 23

2. Standardised Treatment Protocol and guidelines

3. Color Codes for Triage
4. Assured service like CEmONC, NICU
5. Improved Quality of Care
6. Reduction in Mortality
7. Reduction in Morbidity

Cochlear implant
1. Infants and young children with profound congenital or prelingual onset of deafness have benefited from
multichannel cochlear implants
2. Cochlear implants are systems which combine internal (surgically implanted) and externally worn
components. These implants consist of four main components: the externals, which include a
microphone, a minicomputer sound (speech) processor, a transmitter; and the internal, an electrode
array.
3. These implants bypass injury to the organ of Corti and provide neural stimulation through the digitization
of auditory stimuli into digital radiofrequency impulses. Specifically, sound is initially detected by the
microphone and then is processed by the speech processor. The speech processor is programmed by an
audiologist to implement (the manufacturer's) proprietary speech processing strategies that are highly
sophisticated manipulations of the input signal.
4. Signals from the speech processor are transmitted across the skin by an FM signal to the internal
receiver, which converts these signals to electrical impulses. Finally, these electrical impulses are sent to
the electrode array located in the cochlea, where electrical fields are created that act on the cochlear
nerve. This is in contrast to the transmission of sound in a healthy ear, which involves the transmission of
sound vibrations to the hair cells of the cochlea, the release of ions and neurotransmitters in the cochlea,
and the transmission of neural impulses to the cochlear nerve and then the brain.
5. Surgical implantation is done under general anesthesia and involves mastoidectomy and widening of the
facial recess. The approach to the cochlea is through the facial recess. After fastening the internal
stimulator package in the mastoid process, the cochlea must be opened in order to insert the electrode
array, which is most commonly done through an opening made in the round window. Care is taken to
avoid contamination of the cochlear fluids by bone dust or blood. After the cochlea is closed, generally
with fascia, the wound is closed.
6. An audiologist performs testing in the operating room to verify the functional integrity of the implanted
device. These electrophysiologic responses from the VIII nerve are critical to determining a starting point
for programming the external device after the wound has healed. A plain x-ray is often performed in the
operating room as well to document placement of the array in the scala tympani.
7. The healing process following surgery is approximately 3-4 wk for a child. During this time, the child
cannot hear. When the child is brought in for the first stimulation using the external equipment,
programs are developed that provide first access to sound. The methods to create the programs entail a
combination of electrophysiologic measures and behavioral testing that is similar to the pediatric
audiologic assessments described above. The initial programs are a starting point, followed by
modifications and enhancements that are based on the parents’ and audiologist's observations of
changing auditory awareness and vocalization.
8. Speech and language therapy is necessary to stimulate language and to teach parents skills to support
speech development.
9. A serious possible complication of cochlear implantation is pneumococcal meningitis. All children
receiving a cochlear implant must be vaccinated with the pneumococcal polyvalent vaccine PCV13, and
rates of pneumococcal meningitis have declined considerably since implementation of the vaccine.
 24

10. Cochlear implantation before age 2 yr improves hearing and speech, enabling more than 90% of children
to be in mainstream education.
Screen time in children
Introduction
1. Screen time is the total time spent per day in viewing screens such as mobile phone, TV, computer,
tablet, or any hand-held or visual device. Screens have become an essential part of our life. Parents,
teachers, and health professionals are concerned about the increase in children’s screen time. Just
like the balanced food that we eat, screens need to be properly chosen and to be consumed in the
right quantity and at the right time. The way we use the screens determines whether it is healthy or
unhealthy.
2. Screen time spent for educational or prosocial activities such as schoolwork, interacting with friends
and relatives, and creating art or music or relaxation is termed positive or healthy, while watching
inappropriate TV shows, visiting unsafe websites, or playing violent video games are few examples of
negative or unhealthy screen time.
For how long can my child use screens? Should I limit screen time?
1. Children below the age of 2 years should not be exposed to any type of screen with the exception of
occasional video call with relatives. Screen time for children between the age of 2 and 5 years should
not exceed 1 hour; the lesser, the better.
2. For older children and adolescents, it is important to balance screen time with other activities that
are required for overall development. These activities include an hour of physical activity (play time),
adequate duration of sleep (recommended sleep time varies with age, for example, adolescents
require 8–9 hours of uninterrupted sleep at night), and time for schoolwork, meals, hobbies, and
family time. If any of these activities is displaced due to screen use, then it is called excessive screen
time and it should be reduced.
What is the effect of using screens for a prolonged time on my child?
1. There are multiple ill effects of excessive screen time on child: Physical health: Obesity, sedentary
lifestyle, disturbed sleep, headache, eye strain, neck, back, and wrist pains
2. Mental health: Delayed speech, hyperactivity, aggression, violence, desire for instant gratification,
poor concentration, FOMO (fear of missing out), FOBLO (fear of being left out), cyberbullying, media
addiction, distorted perception of sex by exposure to pornography, drug use, self-harm, anxiety, and
depression
3. Social: Reduced socialization and social anxiety
4. Scholastic: Decreased academic performance
Are there any benefits of the digital devices?
When screens are used in moderation in a balanced and healthy way, they have many benefits:
1. Encourage learning and knowledge Act as a tool for communicating with friends and family and
promote social interaction. Healthy co-viewing and co-playing using digital platforms improve child
and parent bonding, recreation, and relaxation.
2. Smartphone Apps such as Saathiya, Calm, and digital platforms such as NIMHANS online yoga class
encourage kids to adopt healthy behaviors and kindle device promotes reading
3. Channels like YouTube and blogging platforms give opportunities to children to display their talents
4. Customized computer programs can improve social behavior in children with autism and study skills
in children with learning problems.
What is the right age to introduce computer, mobile, and television for child?
1. For children <2 years, social interaction is required for healthy brain development. Use of digital
devices in this age group can result in delayed speech, hyperactivity, and poor social skills. Hence,
screens should be avoided for children <2 years.
 25

2. At 2 years, you could introduce digital devices such as computer and television but you should view
the screens along with the children and prefer educative interactive programs for a short duration of
time.
3. Adolescents could be given ordinary mobile phones and preferably not smartphones mainly to
maintain contact with you when they are outside home.
4. Older children and adolescents may be allowed for the use of smartphones for educational and
recreational purposes under parental monitoring for limited duration.
How can I motivate my child to use media in a healthy way?
1. Ensure a warm, nurturing, supportive, fun-filled, and secure environment at home.
2. Children follow rules, if they are guided in a respectful and empathetic manner.
3. Do not use a screen for calming or distracting a child.
4. Balance screen time with adequate time for sleep, physical activity, study, family, meals, and hobby
time.
5. Screens should be switched off 1 hour before bedtime, as blue light emitted from devices disturbs
sleep. The correct posture to be adopted while sitting in front of the computer and the mobile phone
is shown in the figures below, respectively.
6. To reduce eyestrain and dryness of eyes, it is important to follow 20-20-20 rule as outlined in the
figure below. Avoid multitasking. While doing offline homework, all digital devices should be
switched off. Keep children safe by co-viewing and monitoring the online content and interactions.
7. Avoid programs and games with violent content. Also, ensure proper privacy settings on the
computer, safe search engines on browsers and apps, and anti-virus software. For young children,
install protective software to restrict access to inappropriate websites.

Sexual abuse in children

Introduction
1. Child sexual abuse (CSA) includes all types of sexual victimization of children – penetrative or non-
penetrative sexual intercourse, pornography, sexual harassment, commercial sexual exploitation, sex
tourism and online exploitation.
2. A recent epidemiological study mentions that the prevalence rates of CSA in Europe, America and
Asia were 9.2%, 10.1% and 23.9%, respectively.
3. Sexual violence takes place in all settings: at home, schools, child care institutions, places of work
and in the community. Information on the prevalence and forms of CSA is very scarce and difficult to
obtain
4. Boys were equally affected and more than 20% were subjected to severe forms of abuse. Several
reports indicate that neighbours, friends, close relatives, and acquaintances and employers at
workplaces are the most common abusers.
5. It isimportant that they acquire the necessary expertise. This communication describes the
management of CSA, focusing on medical history, physical examination and forensic aspects.
Physicians also need to be aware of prevention of CSA and the POCSO Act, which clearly mentions
their responsibility in the management of CSA.
6. Every case of sexual assault is a medical emergency for which free treatment is mandatory at
government or private medical facilities, and no document or precondition is necessary for providing
emergency medical care. A victim of CSA may approach a health facility directly for treatment, with a
police requisition after police complaint, or with a court directive. The hospital is bound to provide
treatment and conduct a medical examination with consent of the child/parent/guardian, depending
upon the age of the child.
Medical evaluation of a child subjected to sexual abuse
 26

1. An informed consent must be obtained, which is required for examination, collection of samples for
forensic examination, treatment and police intimation. If the child is over 12 years of age, consent
should be sought from the child. For those below the age of 12 years, a parent or the guardian is
required to providing it.
2. The examination is conducted in the presence of a woman nominated by the head of the medical
institution.The elements of physical examination include particular attention to the following
a. general observation and inspection of the anogenital area, looking for signs of injury or
infection and noting the child’s emotional status.
b. examination of mons pubis, labia majora and minora, clitoris, urethral meatus, hymen,
posterior fourchette, and fossa navicularis.
c. visualization of the more recessed genital structures, using handheld magnification or
colposcopy as necessary.
d. collection of specimens for sexually transmitted disease (STD) screening and forensic
evidence collection.
e. Forensic evidence includes blood, semen, sperm, hair or skin fragments that could link the
assault to an individual person, as well as debris (e.g., carpet fibers) that could help to
identify the location. Collection of specimens and material should be done if sexual contact
has occurred within 96 hours of the physical examination.
3. The management of CSA includes the following:
a. Treatment of sexually transmitted diseases (STDs) is carried out with appropriate
medications.
b. In post-menarchal girls, the likelihood of pregnancy and the need for emergency
contraception is considered.
a. Emotional support is provided.
b. CSA, whether confirmed or strongly suspected, must be reported to the appropriate
authorities.
c. Detailed, well-documented medical records must be kept, since these are crucial in legal
proceedings, which may take place after a lapse of long periods.
d. Referral to a mental health specialist should be made in all cases, which is required for
evaluation and treatment of acute stress reaction, and subsequently posttraumatic stress
disorder (PTSD).
One Stop Centers (OSC)
1. The Ministry of Women & Child Development, Govt. of India is establishing One Stop Centers
(OSC) to provide support and assistance to victims of gender violence. Thus, comprehensive
services, including medical, police, psychosocial counseling, legal aid, shelter, referral and
facilities for video-conferencing are provided ‘under one roof.’
2. For those below 18 years, these are undertaken in coordination with authorities under the
Juvenile Justice Act, 2011 and the POCSO Act, 2012.
Role of Mental Health Professionals
1. Mental health professionals have an important role in assisting the child and the family during
examination and for comprehensive management of CSA. Victims of CSA are vulnerable
topsychoemotional distress and may have a tendency to self-harming behavior.
2. Experts can counsel the child and help to reduce the emotional burden of trauma. Appropriate
measures must be taken to prevent further abuse, trauma and re-victimization.
Prevention of child sexual abuse
1. CSA should be considered a preventable crime.
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2. Adolescents need more detailed knowledge of body physiology, sexual intercourse, pregnancy,
healthy relationships and sexual violence, which is best provided at schools by trained teachers. This
information can be packaged as health and family life education, thus avoiding the term ‘sex
education’. The parents should ask the child to report any unusual behavior by adults or older
children. Their accounts must not be ignored and the child never made to feel guilty.
3. CHILDLINE 1098: This is an emergency telephonic helpline, which can link children in situations of
abuse and neglect with sociolegal services.
The law on child sexual abuse
In November 2012, India adopted The Protection of Children from Sexual Offences Act (POCSO) meant to
provide for protection of children from the offences of sexual assault and safeguarding the interest and
well being of children.
Infanticide
Definition:-
1. Infanticide – Killing of infant (birth to 12 months).
2. Feticide – Killing of foetus at any time prior to birth.
3. Filicide – Deliberate killing of Child by own parents. 1. Maternal Filicide 2. Paternal Filicide
4. Neonaticide – Killing of an infant within 24 hours of birth.
Causes:
1. Patriarchy:
The word “Patriarchy” literally means the rule of father or the “patriarch” and originally it
was used to describe specific type of “male-dominant” family. The first lessons of patriarchy
are learnt in the family where the head of the family is a man father. In a patriarchal family
the birth of male child is preferred to that of a female.
2. Son Preference:
Daughters on the other hand become part of their husband’s family and do not contribute to
their parents’ family any more. Moreover it is also believed that moksha can only be attained
if the last rites of the parents are performed by the son. Apart from this, sons are seen as
bread earners for the family and daughters are treated as economic burden.
3. Dowry:
Various research studies have pointed out dowry as one of the important reasons for female
foeticide where the bride's family gives the groom's family money and/or gifts. Hence
daughters are considered a liability for the family.
4. Poor status of women:
Although constitution of India treats women equal to men yet they have poor status in the
society which is evident through discrimination they face during their life time.
5. Two children norm:
Another reason given for the prevalence of sex selective abortion is promoting adherence to
two children norm in the country. People do not welcome the first daughter in family, but
since they have to stick to two children norm, they cannot afford second daughter which
subsequently leads to female foeticide or infanticide.
Infanticide in Tamilnadu
1. In Tamil Nadu, it was observed that the most commonly used methods for killing infants include
"poisoning by the latex of the calotropis plant, organophosphate poisoning (pesticide), sedative
overdose, strangulation, neglect (starving the baby to death, which does not leave any forensic
evidence), feeding the child paddy grain soaked in milk or juice extracted from tobacco leaves.
Asphyxiation by swaddling the baby in a wet cloth is also practised".
 28

2. In South India, certain districts of Tamil Nadu are known for this inhuman practice even now. Districts
like Salem (826), Dharmapuri (878), Theni (893) and Namakkal (896) recorded lowest figures in sex
ratio. There are certain taluks in these districts which reported shocking anomalies in Juvenile sex
ratios (Omallur (589), Etappadi (714), Pennagarm (776) and Mettur (790).
3. In Tamil Nadu, higher infant mortality rate among boys is reversed to be higher for girls and in some
districts, such as Dharmapuri district, it is as much as 69% higher for girls than for boys. In that same
district as many as 59.4% of the female infant deaths were cases of infanticide.
Consequences:
Decline in Child Sex Ratio: Killing a girl child before or after she is born has an adverse effect on the
sex ratio, has other negative consequences and leads to further social evils.
Cradle baby scheme
The Cradle Baby Scheme (CBS) was launched in 1992 by the government of Tamil Nadu in response
to the practice of female infanticide.

Delivery point screening

Newborn screening at delivery points in India is part of the Rashtriya Bal Swasthya Karyakram (RBSK):
Purpose
To identify birth defects early so that children can receive medical and surgical treatment
Methods
Delivery point staff screen for visible birth defects by performing a head-to-toe examination. They
also use low-cost instruments and clinical examinations to identify functional birth defects.
Who performs screening
Accredited Social Health Activists (ASHAs) screen for birth defects during home visits. They use
simple tools to detect gross birth defects.
When screening occurs
Delivery points: Screening occurs at delivery points
Home visits: ASHAs screen babies born at home and in institutions up to 6 weeks of age
Anganwadis: Children are screened biennially from 6 weeks to 6 years
Schools: Children are screened once a year from 6 years to 18 years
Some conditions screened for include:
1. Visible birth defects
2. Congenital heart diseases
3. Eye conditions like congenital cataract and congenital glaucoma
4. Retinopathy of prematurity (ROP)
5. Metabolic disorders like congenital hypothyroidism, congenital adrenal hypoplasia, glucose-6-
phosphate dehydrogenase (G6PD) deficiency, and sickle cell disease

Mus Quan initiative

Introduction
Mus Quan in Hindi means “smile”. Launched by the Hon’ble Health Minister on 17 th September 2021. A
focused approach towards ensuring delivery of Quality Care to paediatric age group (0-12 years) at the
public health facilities
Goal
MusQan aims to ensure provision of quality child-friendly services in public health facilities to reduce
preventable newborn and child morbidity and mortality.
Objectives
1. To reduce preventable mortality and morbidity among children below 12 years of age.
 29

2. To enhance Quality of Care (QoC) as per National Quality Assurance Standards (NQAS).
3. To promote adherence to evidence-based practices and standard treatment guidelines & protocols.
4. To provide child-friendly services to newborn and children in humane and supportive environment.
5. To enhance satisfaction of mother and family, seeking healthcare for their child.
Strategy
1. Strengthen Clinical Protocols and Management Processes
2. Ensuring Child Friendly Services
3. Strengthening of Referral and Follow-up Services
4. Ensuring Provision of Respectful and Dignified Care
Framework
1. Central Quality Supervisory Committee
2. State Quality Assurance Committee & Units
3. District Quality Assurance Committee & Units
4. Quality-Teams:
5. Quality Circles: Each Quality Circle comprises of Ledical officer/Paediatrician Incharge of relevant
department such Paediatric ward, SNCU, NBSU, Paediatric OPD, Immunisation clinic.
Departments to be Included Under MusQan
1. Paediatric OPD
2. Paediatric Ward
3. SNCU
4. Nutrition Rehabilitation Centre
Steps for Implementation of MusQan
1. Assessment: The Quality team, will undertake the assessment of the departments utilising MusQan
checklists. Simultaneously departmental quality circles will capture the indicators (departmental as
well target indicators under the ‘MusQan’) and parent/family satisfaction.
2. Identifying gaps: The MusQan quality tools (checklists) along with results of target indicators, audits
(medical, death, prescription), competency evaluation, etc. will help the facility to identify gaps at
the structural and process level. Each of these will be classified as critical and non-critical after due
analysis.
3. Planning Interventions: Non-critical gaps are easy to manage and mostly require direct action to
close them. However, critical gaps require further scoping and application of scientific methodology
i.e., Plan, Do, Check, Act (PDCA) to attain the improvement(s). Facilities are encouraged to plan and
undertake rapid improvement events (RI events).
4. Undertaking improvement steps: Once the facility/department identifies the critical gaps based on
their assessments, the facility level quality team or departmental quality circle is expected to
undertake specific steps for improvement/ closure of identified gaps.
Certification:
Once the facility has substantially improved and is able to achieve at least 70% or more in NQAS
assessment tools, it can apply for the State & National certification.

Adolescent friendly health services:

1. Adolescent Reproductive and Sexual Health programme (ARSH)
Introduction
1. Adolescent Reproductive and Sexual Health programme (ARSH) focusses on reorganizing the existing
public health system in order to meet service needs of adolescents.
2. ARSH programme envisages creating an enabling environment for adolescents to seek health care
services through a spectrum of programmatic approaches:
 30

a. Facility based health Clinics;

b. Counselling
c. Community based interventions
d. Capacity building for service providers.
Adolescent Friendly Health Clinics (AFHC):
1. Through Adolescent Friendly Health Clinics, routine check-up at primary, secondary and tertiary
levels of care is provided on fixed day clinics.
2. At present 6,302 AFHCs are functional across the country providing services, information and
commodities to more than 2.5 million adolescents for varied health related needs such as
contraceptives provision, management of menstrual problems, RTI/STI management, antenatal care
and anaemia.
Facility based counselling services:
1. Counselling services for adolescents on important issues such as nutrition, puberty, RTI/STI
prevention and contraception, delaying marriage and childbearing, and concerns related to
contraception, abortion services, pre-marital concerns, substance misuse, sexual abuse and mental
health problems are being provided through recruitment and training of dedicated counsellors.
2. At present 881 dedicated ARSH counsellors are providing comprehensive counselling services to
adolescents across the country. In 23 States/UTs, 1439 ICTC counsellors have been enrolled to
provide sexual and reproductive health counselling to adolescents.
Outreach activities:
Outreach activities are being conducted in schools, colleges, teen clubs, vocational training centres,
during Village Health Nutrition Day (VHND), health melas and in collaboration with self-help groups
to provide adequate and appropriate information to adolescents in spaces where they normally
congregate.
Weekly Iron and Folic Acid Supplementation (WIFS)
1. Ministry of Health and Family Welfare has launched the Weekly Iron and Folic Acid Supplementation
(WIFS) Programme to meet the challenge of high prevalence and incidence of anaemia amongst
adolescent girls and boys. The long term goal is to break the intergenerational cycle of anaemia, the
short-term benefit is of a nutritionally improved human capital.
2. The programme, implemented across the country, both in rural and urban areas, will cover 10.25
crore adolescents.
3. The key interventions under this programm re as follows:
a. Administration of supervised weekly iron-folic acid supplements of 100 mg elemental iron
and 500 ug folic acid using a fixed day approach.
b. Screening of target groups for moderate/severe anaemia and referring these cases to an
appropriate health facility.
c. Biannual de-worming (Albendazole 400 mg), six months apart, for control of helminths
infestation.
d. Information and counselling for improving dietary intake and for taking actions for
prevention of intestinal worm infestation.
Menstrual Hygiene Scheme
1. he Ministry of Health and Family Welfare has launched scheme for promotion of menstrual hygiene
among adolescent girls in the age group of 10-19 years in rural areas. This programme aims at
ensuring that girls have adequate knowledge and ‘information about menstrual hygiene and have
access to high quality sanitary napkins along with safe disposal mechanisms.
2. Key activities under the scheme include:
 31

a. Community based health education and outreach in the target population to promote
menstrual health;
b. Ensuring regular availability of sanitary napkins to the adolescents;
c. Sourcing and procurement of sanitary napkins;
d. Storage and distribution of sanitary napkins to the adolescent girls;
e. Training of ASHA and nodal teachers in menstrual health; and safe disposal of sanitary
napkins.
National mental health program
Introduction.
1. The National Mental Health Programme was launched during 1982 with a view to ensure availability
of Mental Health Care Services for all, especially the community at risk and underprivileged section
of the population.
2. A National Advisory Group on mental health was constituted under the Chairmanship of the
Secretary, ministry of Health and Family Welfare for the effective implementation of the National
Health Programme.
3. Eleven institutions have been identified for imparting training in basic knowledge and skills in the
field of mental health to the primary health care physicians and paramedical personnel. At present
this programme covers 517 districts in 36 states.
The aims of the NMHP are:
1. Prevention and treatment of mental and neurological disorders and their associated disabilities;
2. Use of mental health technology to improve general health services; and
3. Application of mental health principles in total national development to improve quality of life.
The objectives of the programme are:
1. To ensure availability and accessibility of minimum mental health care for all in the foreseeable
future, particularly to the most vulnerable and underprivileged sections of population.
2. To encourage application of mental health knowledge in general health care and in the social
development.
3. To promote community participation in the mental health services development, and to stimulate
efforts towards self-help in the community.
The programme strategies are:
1. Integration of mental health with primary health care through the NMHP;
2. Provision of tertiary care institutions for treatment of mental disorders;
3. Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory
institutions like the Central Mental Health Authority, and State Mental Health Authority.
District Mental Health Programme components are:
1. Training programme of all workers in the mental health team at the identified nodal institute in the
state;
2. Public education in mental health to increase awareness and to reduce stigma;
3. For early detection and treatment, the OPD and indoor services are provided; and
4. Providing valuable data and experience at the level of community to the state and centre for future
planning, improvement in service and research.
5. District Mental Health Programme has now incorporated promotive and preventive activities for
positive mental health which includes:
a. School mental health services: Life skills education in schools, counselling services.
b. College counselling services: Through trained teachers/councellors.
c. Work place stress management: Formal & Informal sectors, including farmers, women etc.
 32

d. Suicide prevention services: Counselling center at district level, sensitization workshops, IEC,
help lines etc.
6. The National Human Rights Commission also monitors the conditions in the mental hospitals along
with the government of India, and the states are acting on the recommendations of the joint studies
conducted to ensure quality in delivery of mental care.
Thrust areas
1. District mental health programme in an enlarged and more effective form covering the entire
country.
2. Streamlining/modernization of mental hospitals in order to modify their present custodial role.
3. Upgrading department of psychiatry in medical colleges and enhancing the psychiatric content of the
medical curriculum at the undergraduate as well as postgraduate level.
4. Strengthening the central and state mental health authorities with a permanent secretariat.
Appointment of medical officers at state headquarters in order to make the monitoring role more
effective.
5. Research and training in the field of community mental health, substance abuse and child adolescent
psychiatric clinics.
The Mental Healthcare Act, 2017
1. The Mental Healthcare Bill, 2013 was introduced in the Parliament in order to protect and promote
the rights of persons with mental illness during the delivery of health care in institutions and in the
community and to ensure health care, treatment and rehabilitation of persons with mental illness, is
provided in the least restrictive environment possible.
2. Further, to regulate the public and private mental health sectors within rights framework, to achieve
the greatest public health good and to promote principles of equity, efficiency and active
participation of all stakeholders in decision making.
3. Suicide has been decriminalized under the Act. The bill received assent of the Hon’ble President of
India on 07.04.2017. The Ministry has constituted a committee of experts for formulating rules and
regulations under the Act.

Developmental assessment scale for Indian infants (DASII)

Introduction
1. Several screening and diagnostic tools have been devised over the due course to ease the
developmental assessment in India. Globally, the most widely used tool for development assessment
in infants is the Bayley Scale of Infant Development (BSID). However, the Developmental Assessment
Scale for Indian Infants (DASII) remains the mainstay in India since it has been standardized in Indian
babies.
2. Developmental outcomes on DASII are being used for the validation of screening tools and
evaluation of various predictors of development such as general movements.
DAS II scale
1. DASII (applicable for 1–30 mo age) is an Indian adaptation of BSID, based on Baroda norms. DASII
consists of 67 and 163 items for motor and mental developmental assessment respectively. For the
clinical context, it provides developmental motor quotient (DMoQ), developmental mental quotient
(DMeQ), and composite developmental quotient (DQ).
2. With a mean DQ of 100 and standard deviation (SD) of 15, 1SD and 2SD below mean correspond to
DQ of 85 and 70, respectively. However, the cutoff points on DASII used for distinguishing normal
from abnormal development are not in agreement across different studies. This is probably due to a
lack of mention of cutoff points in the DASII manual and existing literature.
 33

3. With DASII being the gold standard for validation of screening tools, there is a dire need to maintain
uniformity. Hence, the current review was undertaken to analyze the heterogeneity in the literature
for interpretation of DASII.
Methodology
1. Motor scale assesses control of gross and fine motor muscle groups. Mental scale assesses cognitive,
personal and social skills development. Both mental development index and psychomotor
development index can be calculated by DASII4.
2. The age placement of the item at the total score rank of the scale is noted as the child’s
developmental age. This converts the child’s total scores to his motor age (MoA) and mental age
(MeA). The respective ages are used to calculate his / her motor and mental development quotients
respectively by comparing them with his chronological age (CA) and multiplying it by 100. (DMoQ =
MoA/CA x 100 and DMeQ = MeA/CA x 100).
3. The composite DQ is derived as an average of DMoQ and DMeQ. A good correlation between
developmental quotients (DQ) (DASII) and social quotients (SQ) (Malin’s Vineland Social Maturity
Scale [VSMS]) has been shown.

National sickle cell anemia mission

Introduction
1. Sickle cell disease is a genetic blood disease which affects the whole life of affected patient. It is more
common in the tribal population of India, but occurs in non-tribals too.
2. The MoHFW tribal health expert committee report has listed sickle cell disease as one of the 10
special problems in tribal heath that affect the tribal people disproportionately, thus making this an
important intervention.
3. Ministry of health under NHM initiated the work on hemoglobinopathies (Thalassemia & Sickle Cell
Disease) in 2016 wherein comprehensive guidelines on prevention and management of
heamoglobinopathies were released and provision of funds towards screening and management of
Sickle cell disease were made.
Mission:
To improve care of all Sickle Cell Disease patients for their better future and to lower the prevalence
of the disease through multi-faced coordinated approach towards screening and awareness
strategies
Vision:
Eliminate sickle cell disease as a public health problem in India before 2047 there is need for
increasing the awareness about the disease in the community, implementation of mass screening
activities.
Aim:
The overall aim is to enable access to affordable and quality health care to all SCD patients, and to
lower the prevalence through awareness, change of practices and screening interventions.
Objectives of the Mission:
1. Provision of affordable and accessible care to all SCD patients
2. To ensure quality of care for SCD patients
3. To reduce the prevalence of SCD
Strategy: The strategy emphasizes on THREE pillars:
1. Health promotion- Awareness generation & pre-marital genetic counselling
2. Prevention: Universal screening and early detection
3. Holistic Management & continuum of care-
 34

a. Management of persons with sickle cell disease at primary, secondary and tertiary health
care levels; treatment facilities at tertiary health care facilities
b. Patient support system
c. Community adoption
Beneficiaries:
1. The program shall be carried out in a mission mode covering the entire population from zero to 18
years of age and shall incrementally include the entire population up to 40 years.
2. While in its initial stage, the mission would prioritize its intervention in high prevalence and tribal
states/UT, the plan would subsequently expand to include all states/UTs in a phase-wise manner with
an incremental approach.
3. The mission aims to cover 7 crore people with screening, counselling for prevention and care for
people with SCD in three and half years.
4. Initially, the focus shall be on 17 states with higher prevalence of SCD viz., Gujarat, Maharashtra,
Rajasthan, Madhya Pradesh, Jharkhand, Chhattisgarh, West Bengal, Odisha, Tamil Nadu, Telangana,
Andhra Pradesh, Karnataka, Assam, Uttar Pradesh, Kerala, Bihar and Uttarakhand.
Primary Prevention
1. Awareness Generation & Premarital Counselling
2. At individual/Household level- Individuals with known or detected SCDs would also be encouraged to
register on Sickle Cell Disease Support Corner, to bridge the gap between patients and health care
services in tribal areas.
3. At Community level: Platforms such as monthly Village Health Sanitation and Nutrition Committee
(VHSNC) etc shall be leveraged to sensitize people on the importance of sickle cell disease and
screening service available at AB-HWCs.
4. Patients Support Groups (PSG) to improve treatment compliance
5. Pre-marital and pre-conception screening backed by genetic counselling services.
6. At Schools: Medical Officer at Primary Health Centre shall conduct talk sessions and counselling at all
schools & colleges including ‘schools tribal residential schools, tribal hostels etc.
7. At Health Care Facility Level: Counsellors at the primary health care centres will be primarily
responsible for providing counselling services to all individuals diagnosed positive with Sickle cell
Anemia.
8. IEC and Mass media: planned IEC/BCC activities under this programme,
9. Engagement of CBOs/NGOs: NGOs working in the area in the sector of health especially tribal health
shall also be utilized for the purpose of mobilization, awareness and providing pre-marital and
prenatal screening and counselling services.

Suicide prevention
Introduction
1. India accounts for almost 25 % of the total male suicides and 37 % of the total female suicides
worldwide. Suicide is especially a concern among younger females and middle-aged men and is the
leading cause of death among people aged 15–39 years in India.
2. The National Suicide Prevention Strategy formulated under the aegis of the Ministry of Health and
Family Welfare (MoHFW), Government of India, was unveiled on November 21, 2022. The strategy
aims to reduce suicide mortality in the country by 10% by the year 2030 and has four main
objectives:
a. To establish an effective surveillance system for suicide within the next 3 years
b. To establish psychiatric outpatient departments to provide suicide prevention services
through the District Mental Health Program in all districts within the next 5 years
 35

c. To integrate a mental well-being curriculum in all educational institutions within the next 8
years
d. To generate research evidence in the context of suicide.
3. India released its first national suicide prevention strategy in November 2022 (National Suicide
Prevention Strategy, 2022).
4. Surveillance of suicidal behavior: regular collection and dissemination of suicide data. Two key
methods of collecting information on regional or national rates of attempted suicide include
community surveys based on self-reported suicidal behaviors and hospital-based records.
5. Means restriction: Restricting access to lethal means is known to prevent suicides.
a. Restriction of access to agricultural pesticides
b. Hanging suicides are difficult to restrict except in controlled environments such as prisons
and hospitals. Policies focusing on removing ligature points and materials in controlled
environments might help reduce hanging suicides in these settings in India.
6. Media’s reporting of suicide: Responsible reporting of suicide in the media should be promoted in
India, as it cannot only help curb copycat suicides but also promote help-seeking behaviors. A
positive step towards achieving this goal was taken recently when the Press Council of India, in 2019,
formally adopted guidelines on responsible reporting of suicides based on the WHO guidelines.
7. Training: Training and education are usually designed for gatekeepers (e.g., primary care physicians
and health care workers) to improve their skills in identifying and treating vulnerable populations.
8. Crisis intervention: One of the most common among them is telephone helplines, designed to help
individuals in suicidal states.
9. Treatment of attempted suicide and postvention: Treatment and postvention are part of tertiary
prevention strategies that focus specifically on individuals affected by suicidal behavior. Treatment
ranges from immediate crisis intervention, i.e., stabilizing an individual brought to the hospital after
an attempted suicide, to long- term interventions such as drug rehabilitation and therapy.

Adolescent problems
Health problems of adolescents
Nutrition or eating disorders.
1. There is increase in nutritional requirements during this period of rapid growth, 56% Indian
adolescent girls are anemic.
2. There is lack of sun-exposure with dark skin pigment. Insufficient intake of dairy products results in
poor intake of calcium and protein intake in addition to calcium and vitamin D deficiency.
3. Anorexia nervosa and bulimia are being increasingly reported among urban Indian youth.
Mental health problems.
1. Adjustment disorder, anxiety disorders, depression, suicide, delinquent behavior, poor body image
and low self-esteem are the psychological problems faced by adolescents.
2. Suicide rates are increasing in adolescents.
Infections.
1. With increased outdoor activity, teens are exposed to TB, HIV, sexually transmitted infections, skin
infections and parasitic infections. Early sexual activity is not uncommon in India. Genital infections
and sexually transmitted infections.
2. Vaginal discharge is common in adolescent girls and may signify physiological leucorrhea of puberty
or endogenous or sexually transmitted infections. PIO occurs commonly in sexually active young
females and can present with abdominal pain with vaginal discharge.
Lifestyle diseases.
 36

1. The prevalence of obesity and overweight is higher in boys than girls. Obesity has strong association
with asthma, sleep disorders, reflux disease, Blount disease, slipped femoral epiphysis, gallstones,
fatty liver and numerous metabolic derangements like type 2 diabetes, dyslipidemia, hypertension
and polycystic ovary disease. Essential hypertension is rising among Indian youth
2. The polycystic ovary syndrome, with a combination of menstrual irregularities and ovarian cysts with
androgen excess like acne or hirsutism, occurs in around 9% of Indian adolescent girls. The condition
has association with other metabolic derangements like obesity, insulin resistance and type 2
diabetes.
Substance abuse.
1. This is an issue in urban as well as rural India. Most of the tobacco and alcohol use starts during
adolescence.
2. Alcohol (21 %), cannabis (3%) and opium (0.4%) are the most prevalent substance abuse other than
tobacco in Indian youth. Addicts are more prone to accidents, injuries, violence, trading sex-for-
drugs, HIV, hepatitis C, sexually transmitted diseases and tuberculosis.
3. Accidents are the major cause of mortality in this age group. Road traffic accidents, burns and
poisoning are leading causes of traumatic mortality and disability in Indian youth. Motor vehicle and
industrial accidents are common in boys whereas burns are commoner in girls.
4. Early warning signs of teen substance use are change in mood, appetite, or sleep pattern; decreased
interest in school or school performance; loss of weight; secretive behavior about social plans; or
valuables such as money or jewelry missing from the home.
5. The use of urine drug screening is recommended when select circumstances are present:
a. psychiatric symptoms to rule out comorbidity or dual diagnoses,
b. significant changes in school performance or other daily behaviors,
c. frequently occurring accidents,
d. frequently occurring episodes of respiratory problems,
e. evaluation of serious motor vehicular or other injuries.
6. Fundamental principles for treatment include accessibility to treatment; utilizing a multidisciplinary
approach; employing individual or group counselling.
7. Preventing drug use among children and teens requires prevention efforts aimed at the individual,
family, school, and community levels. Programs should enhance protective factors (parent support)
and reduce risk factors (poor self-control).
Adolescent pregnancy.
1. Adolescent pregnancies are common in India, mainly because of early marriage. 22% of young Indian
women have their first childbirth before 18 yr of age. As compared to adult pregnancy, they are also
at a higher risk for preeclampsia, preterm labor and postpartum hemorrhage. Prolonged and
obstructed labor is common in adolescent pregnancies and young girls are two to four times more
likely to die during childbirth as compared to adult pregnant females.
2. Neonatal, infant and child mortality rates are higher in children delivered to adolescent mothers.
Lack of sex education.
3. The majority of Indian youth do not get formal sex education in an effective way. Peers, books and
magazines are their main sources of information about sex. Parents and teachers often fail to discuss
issues like masturbation, safe sex, dating, abortion, HIV and sexually transmitted diseases
Environmental and Social Challenges Pollution.
1. The incidence of asthma is increasing. There is ongoing research into the role of electromagnetic
exposure from communication devices in disorders like childhood leukemia, brain tumors and
immune dysregulation.
 37

2. Media. Due to inability to separate fact from fantasy, adolescents succumb to the glamorous
portrayal of tobacco or alcohol consumption, unrealistic expectations, physical aggression,
destructive behavior and unprotected sex.
3. Peer pressure. Peer formation is a part of adolescent social development including risk taking
behavior and initiation of substance abuse.
4. Academic and emotional stress. While most adolescents have adequate coping skills, some may have
serious adjustment problems resulting in various psychological and somatic effects.
5. Early marriage. Though the legal age for marriage in India is 18 yr for girls, many states still have the
practice of childhood and early marriage.

POCSO ACT
1. The POCSO Act, 2012 provides for protection of children from offences of sexual assault, sexual
harassment and pornography with due regard to safeguarding the interest and wellbeing of children
under 18 years of age.
2. The Act for the first time, defines “penetrative sexual assault”, “sexual assault” and “sexual harassment”.
The offence is considered graver if it is committed by a police officer, public servant, any member of the
staff at a remand home, protection or observation home, jail, hospital or educational institution, or by a
member of the armed or security forces.
Child Sexual Offences under POCSO Act, 2012 & Punishment:
Act Punishment
Section 3: Penetrative Sexual Assault: Inserting Section 4: Not less than seven years of
body part or object in a child, or making a child does imprisonment which may extend to imprisonment
this with another. for life, and fine
Section 5 Aggravated Penetrative Sexual Assault: Section 6: Not less than ten years of imprisonment
Penetrative sexual assault by a police officer, which may extend to imprisonment for life, and
member of armed forces, public servant, staff of fine.
remand home, jail, hospital or school.
Section 7: Sexual Assault: With sexual intent Section 8: Not less than three years of
touching the private parts of a child. imprisonment which may extend to five years, and
fine.
Section 9: Aggravated Sexual Assault: Sexual assault Section 10: Not less than five years of
by a police officer, member of armed forces, public imprisonment which may extend to seven years,
servant, staff of remand home/jail/hospital/school, and fine.
etc, and other acts of sexual assault by any person
as mentioned in the second part of section 5, except
making a girl child pregnant.
Section 11: Sexual Harassment of the Child with Section 12: Up to three years of imprisonment and
sexual intent: fine
• showing any object/body part, or making any
gesture aimed at a child
• making a child exhibit her body
• enticing or threatening to use a child for
pornography
Section 13: Use of Child for Pornographic Purposes Section 14 (1): Imprisonment up to five years and
fine and in the event of subsequent conviction, up
to seven years and fine.
 38

Section 14 (2): Penetrative sexual assault by directly Section 14 (2): Not less than ten years of
participating in pornographic acts imprisonment, which may extend to imprisonment
for life, and fine.
Section 14 (3) Aggravated penetrative sexual Section 14 (3) Rigorous imprisonment for life and
assault by directly participating in pornographic acts fine
Section 14 (4) Sexual assault by directly Section 14 (4) Not less than six years of
participating in pornographic acts imprisonment which may extend to eight years,
and fine
Section 14 (5) Aggravated sexual assault by directly Section 14 (5) Not less than eight years of
participating in pornographic acts imprisonment which may extend to ten years, and
fine
Section 15 Storage of pornographic material Section 15 Three years of imprisonment and / or
involving a child for commercial purposes fine
Section 21 Punishment for failure to report or Section 21
record a case by (i) Any person; (ii) Any person, (i) Imprisonment of either description which may
being in charge of any company or an institution. extend to six months or with fine or with both
(This offence does not apply to a child) (ii) Any person, being in charge of any company or
an institution (by whatever name called) who fails
to report the commission of an offence under sub
section
(1) of section 19 in respect of a subordinate under
his control shall be punished with imprisonment for
a term which may extend to one year and with fine.
Section 22 (1) Punishment for false complaint or Section 22
false (1) Imprisonment for a term which may extend to
information in respect of an offence committed six months or with fine or with both.
under sections 3, 5, 7 and section 9 solely with the (3) Imprisonment which may extend to one year or
intention to humiliate, extort or threaten or defame with fine or with both
him. (2) False complaint or providing false
information against a child knowing it to be false,
thereby victimising such child in any of the offences
under this Act. (This offence does not apply to a
child)

POSHAN ABHIYAN
Introduction
Government of India has launched “Poshan Abhiyan” on 18th December 2017 for a period of three
years commencing from 2017-18, in all 36 states/UTs. The goals are to achieve improvement in
nutritional status of children from 0-6 years, adolescent girls, pregnant women and lactating mothers
with fixed targets.
Background
8. POSHAN Abhiyaan aims to reduce malnutrition, through a life-cycle concept, adopting a synergised
and result-oriented approach. Implemented by the Ministry of Women and Child Development
(MWCD), Government of India, the target of the mission is to bring down stunting in children 0-6
years of age from 38.4% to 25% by 2022.
 39

9. It also aims to reduce anaemia among women and adolescent girls in the age group of 15-49 years
and reduce low birth weight.
10. The POSHAN Abhiyaan intends to achieve its goals by focusing on:
a. mobile-based information technology tools for improved service delivery and monitoring.
b. multi-sectoral planning and monitoring actions from the state to block level for improved
nutrition outcomes;
c. capacity building of Integrated Child Development Services (ICDS) functionaries on nutrition
counselling of pregnant women and mothers of children up to two years of age;
d. community mobilisation and behaviour change communication; and
e. providing performance-based incentives for community nutrition and health workers, and
states.
11. It ensures convergence of various programmes i.e. anganwadi services, Pradhan Mantri Matru
Vandana Yojana; schemes for adolescent girls of Ministry of Women and Child Development; Janani
Suraksha Yojana; National Health Mission of Ministry of Health and Family Welfare; Swachh Bharat
Mission of Ministry of Jal Shakti etc.
12. The objectives and targets are as follows:
a. Prevent and reduce stunting in children (O—6 years) By 6 per cent (2 per cent/ year)
b. Prevent and reduce under nutrition and underweight prevalence in children (0-6 years) By 6
per cent (2 per cent/ year)
c. Reduce the prevalence of anaemia By 9 per cent (3 per cent/ year) among children (6-59
months)
d. Reduce the prevalence of anaemia among girls and women in the age group (15-49 years) By
9 per cent (3 per cent/ year)
e. Reduce low birth weight (LBW) By 6 per cent (2 per cent/ year)
13. The Abhiyan aims to reduce malnutrition in the country through a life cycle approach.
14. Anganwadi Centres are equipped with Smart phones and Growth Monitoring devices (GMDs) such as
Infantometer, Stadiometer, Weighing Scale for Mother and Infant.
15. 5 Pillars of POSHAN Abhiyaan National Nutrition Mission

5 Pillars of POSHAN Abhiyaan

Pillar Poshan Abhiyaan ICDS-Common • With the software, the nutritional status will be
1 Application Software (CAS) monitored.
• Workers for AWWs and Supervisors will receive a
smart phone.
• To measure the growth of the infant, mother, and
kid, AWWs and Supervisors will be given growth
monitoring tools such a stadiometer,
infantometer, and weighing scales.
Pillar Convergence Action Planning • It aims to ensure the convergence of all nutrition-
2 related schemes on the target population.
Pillar Capacity Building of Poshan Abhiyaan ICDS • Anganwadi workers are participating in a capacity-
3 officials/functionaries through the building & learning programs by participating in
Incremental Learning Approach (ILA) existing supervisor meetings.
• The incremental Learning Approach includes 21
thematic modules for AWWs and Supervisors.
 40

Pillar Jan Andolan (Behaviour Change • The Abhiyaan will be managed as a Jan Andolan
4 Communication and Community with desired public involvement.
Mobilisation) • A community-based event will be held once a
month to raise awareness and address issues.
Pillar Performance Incentives • Capacity building should be planned alongside
5 improved service delivery.
• Front-line workers will be given incentives for
their efforts.

Nutrition rehabilitation centers (NRC)

3. Severe acute malnutrition is an important contributing actor for most deaths among children suffering
from common childhood illness such as diarrhoea and pneumonia. Deaths among these malnourished
children are preventable, provided timely and appropriate actions are taken. NRCs are facility based units
providing medical and nutritional care to Severe Acute Malnutrition (SAM) children under 5 years of age
who have medical complications. In addition special focus is on improving the skill of mothers on child
care and feeding practices so that the child continues to get adequate care at home.
4. The services provided at the NRCs include:
a. 24 hours care and monitoring of the child;
b. Treatment of medical complication;
c. Therapeutic feeding;
d. Sensory stimulation and emotional care; e. Counselling on appropriate feed, care and hygiene;
e. Demonstration and practice-by-doing on the preparation of energy dense food using locally
available, culturally acceptable and affordable food items;
f. Social assessment of the family to identify and address contributory factors; and
g. Follow up of the children discharged from the facility.
Management of medical complications in a child with SAM at health facility
6. Triage is the process of rapidly screening sick children. Triage must be done for all paediatric patients
coming to the health facility. The first step is to check every child for emergency signs and provide
emergency treatment as necessary, keeping in mind the ABCD steps: Airway, Breathing, Circulation,
Coma, Convulsion and Dehydration.
7. Assessment at admission: The child should be assessed by taking detailed history and should be
examined for the signs of under-nutrition.
Principles of hospital-based management:
2. The principles of management of SAM are based on 3 phases: stabilization phase, transition phase
and rehabilitative phase.
8. Stabilization Phase: Children with SAM without an adequate appetite and/or a major medical
complication are stabilized in an in-patient facility. This phase usually lasts for 1-2 days. The feeding
formula used during this phase is Starter diet which promotes recovery of normal metabolic function
and nutrition - electrolytic balance. All children must be carefully monitored for signs of overfeeding
or over hydration in this phase.
9. Transition Phase: This phase is the subsequent part of the stabilization phase and usually lasts for 2-3
days. The transition phase is intended to ensure that the child is clinically stable and can tolerate an
increased energy and protein intake. The child moves to the Transition Phase from Stabilization
Phase when there is:
i. Atleast the beginning of loss of oedema.
ii. Return of appetite.
 41

iii. No nasogastric tube, infusions, no severe medical problems.

iv. Is alert and active
The ONLY difference in management of the child in transition phase is the change in type of diet.
There is gradual transition from starter diet to catch up diet. The quantity of catch up diet given is
equal to the quantity of starter diet given in stabilization phase.
10. Rehabilitation Phase: Once children with SAM have recovered their appetite and received treatment
for medical complications they enter Rehabilitation Phase. The aim is to promote rapid weight gain,
stimulate emotional and physical development and prepare the child for normal feeding at home.
The child progresses from transition phase to rehabilitation phase when:
a. S/he has reasonable appetite; finishes > 90% of the feed that is given, without a significant
pause.
b. Major reduction or loss of oedema.
c. No other medical problem.
The ONLY difference in management of the child in transition phase is the change in type of diet.
There is gradual transition from starter diet to catch up diet. The quantity of catch up diet given is
equal to the quantity of starter diet given in stabilization phase.
Micronutrient supplementation
3. Vitamin A: Give Vitamin A in a single dose to all SAM children unless there is evidence that child has
received vitamin A dose in last 1 month. Recommended oral dose of Vitamin A according to
child’s age:
<6 months — 50,000 IU
6-12 months or if weight <8 kg 100,000 IU
>12 months 200,000 IU
Give same dose on Day 1, 2 and 14 if there is clinical evidence of vitamin A deficiency.
IM treatment should be used in children with severe anorexia, oedematous malnutrition, or septic
shock. Only water based formulations and half of oral dose should be used.
4. Other micronutrients should be given daily for at least 2 weeks:
a. Multivitamin supplement (should contain vitamin A, C, D, E and B,, and not just vitamin B
complex): Twice recommended daily allowance.
b. Folic acid: 5 mg on day 1, then 1 mg/day.
c. Elemental Zinc: 2 mg/kg/day.
d. Copper: 0.3 mg/kg/day (if separate preparation not available use commercial preparation
containing copper).
e. Iron: child Start being daily on iron catch supplementation up diet. Give after elemental two
days of iron the in the dose of 3 mg/kg/day in two divided doses, preferably between meals.
(DO not give iron in stabilization phase).
Follow-up of children discharged from NRC
5. Close collaboration and information sharing between NRC and community based care ( at PHC, sub-
centre and AWC) are essential. The list of SAM children discharged from NRC should be shared with
area specific ANM and ICDS supervisors. These children should be enrolled in the anganwadi centre
and given supplementary food as per the guidelines. The AWWs should prioritize these children for
home visits, every week in the first 4 weeks and then once in 2 weeks till the child is discharged from
the programme.
6. During the home visits, AWW should observe feeding and provide appropriate counselling and
support to the mother.
7. These children should be weighed every week at AWC. The ASHA and AWW should ensure that these
children should return for the scheduled follow-ups at the NRC.
 42

8. Incentive of Rs 50 can be provided to ASHA for accompanying the child to the NRC and motivating
the mother to stay at NRC for atleast 7 days till the child is stabilized and has started to eat.
Additional incentive of Rs 50 may be given for each follow-up visit by the child, upto a maximum of
three visits.
Sleep hygiene
Good sleep hygiene is an important basic treatment element for sleep disorders regardless of the cause.
Sleep hygiene provides an essential foundation for other management approaches, but is not a sufficient
treatment for insomnia on its own.
Preschoolers (ages 3-5 years) generally need between 10-13 hours of sleep per night, and school-age
children (ages 6-13 years) need between 9-11 hours of sleep per night.
Tips:
1. Maintain a regular bedtime and wakeup schedule, even on weekends and days off. This is one of the
most important ways to train your body to know when to sleep, and a regular routine helps regulate
your body’s internal clock.
2. Make the last hour before bed a “wind-down” time. Have a light carbohydrate snack (e.g., crackers,
bread, cereal) during this time. Don’t engage in activities that are stimulating or mentally active (i.e.
watching drama/thriller movie, discussion about charged topics such as finances, etc).
3. Eat regular meals every day. Regularity in meals will also help to regulate your internal body clock.
4. Avoid caffeinated products for several hours before bedtime. Remember even decaffeinated drinks
have caffeine in them. It also takes longer to break down caffeine when you get older, so even 1 cup
of coffee might linger around for longer.
5. Make sure your sleeping conditions, including your bed, are comfortable as possible. Wear loose
fitting clothes if possible. Your room should be dark and quiet and minimize ambient light and
sounds. If you are sharing a bed with a snoring, cover-stealing, or restless partner, make separate,
temporary sleeping arrangements until you reestablish a satisfactory sleeping pattern.
6. The temperature of your bedroom should be comfortable and on the cool side (around 65-68°F).
Exercise regularly, but do not engage in activities that raise body temperature (e.g., warm baths,
aerobic activity) within 1.5 hours of bedtime.
7. If you can’t sleep, get up and pursue some relaxing activity, such as reading or knitting, until you feel
sleepy, do not lie in bed worrying about getting to sleep.

Millennium developmental goal focused on children

Introduction
1. With a view to sustaining the overall development by eradicating facets of poverty in different
dimensions in the global countries, all the member countries numbering 147, gathered at the UN
Millennium Summit in New York in September 2000 and designed eight development goals along
with 18 time bound targets and 48 indicators for measuring the progress. Since then, the Millennium
Development Goals (MDGs) have become the most widely accepted yardstick of development efforts
by Governments.
2. The MDGs represent the collective desire of all the nations across the globe to provide a better
future for the millions of citizens affected by poverty.
Eight time-bound and measurable goals:
1. Halving Poverty and Hungry: In order to achieve the goal of halving income-poverty and hunger,
India has to reduce the population below BPL from 37.5 per cent in 1990 to 18.75 per cent in 2015
at the National level and from 40.90 per cent to 20.45 per cent at the State level.
2. Universal Primary Education: With a view to attaining the goal of universal primary education, the
enrolment rate should be increased to 100 per cent and the drop out rate to be wiped out by 2015.
 43

3. Gender Equality in Education: The gender bias in providing education has led to a gap in literacy
rates between male and female. The literacy rate of male and female in 1991 was 74 and 51
respectively, which later increased to 84 and 64 in 2001. The promotion of female participation at all
levels will propel to reach equal female male level by 2015.
4. Reducing Infant Mortality Rate: Reducing the mortality rate of infants and under 5 age group invites
much attention. In India, the death rate of 125 per thousand live births in 1988-92 has to be
brought down to 42 by 2015.
5. Reducing Maternal Mortality Rate: The policy of the Government to take care of the pregnant
women till lactating period was initiated long back. At the national level it was envisaged to bring
down MMR (per one lakh live births ) from 437 in 1991 to 109 at the end of 2015.
6. Combat HIV / Malaria and other Congenial Diseases:
a. Halt and reverse the spread of HIV/AIDS
b. Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
c. Halt and reverse the incidence of malaria and other major diseases
7. Ensuring Environment Sustainability and access to safe drinking water:
a. Integrate principles of sustainable development into country policies and programmes;
reverse the loss of environmental resources
b. Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss
c. Halve the proportion of people without access to safe drinking water and basic sanitation
d. Improve the lives of at least 100 million slum dwellers by 2020
8. Develop a global partnership for development
a. Develop further an open, rule-based, predictable, non-discriminatory trading and financial
system
b. Address special needs of the least developed countries, landlocked countries and small
island developing States
c. Deal comprehensively with developing countries’ debt
d. In cooperation with pharmaceutical companies, provide access to affordable essential drugs
in developing countries
e. In cooperation with the private sector, make available the benefits of new technologies,
especially information and communications technologies

Indian newborn action plan

Introduction
1. In India, Newborn Action Plan (INAP) developed in response to the global Every Newborn Action Plan
(ENAP), was launched in June 2014.
2. Goal 1: Ending Preventable Newborn Deaths to achieve “Single Digit NMR” by 2030, with all the
states to individually achieve this target by 2035
Goal 2: Ending Preventable Stillbirths to achieve “Single Digit SBR” by 2030, with all the states to
individually achieve this target by 2035
Implementation
1. The INAP will be implemented within the existing RMNCH+A framework.
2. Six intervention packages for stillbirths and newborn health includes:
a. Pre-conception and antenatal care;
b. Care during labour and childbirth;
c. Immediate newborn care;
d. Care of the healthy newborn;
e. Care of small and sick newborn; and
 44

f. Care beyond newborn survival.

3. The interventions have been categorized as:
a. Essential [E], to be implemented universally
b. Situational [S], implementation dependent on epidemiological context
c. Advanced [A], implementation based on health-system capacity of the state/district
4. The care providers are:
a. Family and Community
b. Outreach/Sub Centre
c. Health Facility
Package 1: Pre-Conception and Antenatal Care:
1. Reproductive Health & Family Planning [E]
a. Adolescent reproductive health
b. Delaying age of marriage and first pregnancy
c. Birth spacing
2. Nutrition related interventions (E)
a. Balanced energy protein supplementation
b. Peri-conceptional folic acid
c. Maternal calcium supplementation
d. Multiple micronutrient supplementation (Iron, Folic Acid & Iodine)
e. Nutrition Counselling
3. Counselling & birth preparedness (E)
4. Prevention against Malaria (S)
5. Antenatal screening for Anemia & Hypertensive disorders of pregnancy (PIH, Preeclampsia,
Eclampsia) [E]
6. Antenatal screening for Malaria [S]
7. Prevention and management of mild to moderate anemia [E]
8. Maternal tetanus immunization [E]
9. Adolescent friendly health services (nutrition and reproductive health counselling) [E]
10. Interval IUCD insertion [E]
11. Antenatal screening & management of Severe anemia, Hypertensive disorders of pregnancy (PIH,
Preeclampsia, Eclampsia), Gestational Diabetes, Syphilis [E]
12. Antenatal screening & management of Hypothyroidism, Hepatitis B, HIV, Malaria [S]
13. Adolescent friendly health clinics (as per RKSK guidelines) [E]
14. Post-partum family planning services including PPIUCD insertion [E]
15. Prevention of Rh disease using anti D immunoglobulin [S]
Package 2: Care during labour and child birth.
1. Skilled birth attendance [E]
2. Clean birth practices [E]
3. Identification of complications and timely referral [E]
4. Pre-referral dose by ANM [E]
a. Antenatal corticosteroids in preterm labour
b. Antibiotics for premature rupture of membranes
5. Emergency obstetric care [E]
a. Basic and Comprehensive
6. Management of preterm labour [E]
a. Antenatal corticosteroids in preterm labour
b. Antibiotics for premature rupture of membranes
 45

Package 3: immediate newborn care.

1. Delayed cord clamping [E]
2. Interventions to prevent hypothermia [E]
a. Immediate drying
b. Head covering
c. Skin-to-skin care
d. Delayed bathing
3. Early initiation and exclusive breastfeeding [E]
4. Hygiene to prevent infection [E]
5. Vitamin K at birth [E]
6. Neonatal Resuscitation [E]
7. Advanced neonatal resuscitation [E]
Package 4: Care of Healthy Newborn
1. Home visits till six weeks by trained ASHA [E]
a. Counselling
b. Prevention of hypothermia, cord care
c. Early identification of danger signs
d. Prompt and appropriate referral
2. Exclusive breastfeeding [E]
3. Clean postnatal practices [E]
4. Immunization [E]
a. BCG
b. OPV
c. Hepatitis B
Package 5: Care of Small and Sick Newborn
1. Thermal care and feeding support (for home deliveries) [E]
2. Integrated management using IMNCI and use of oral antibiotics [E]
3. Injectable Gentamicin by ANMs for sepsis [E]
a. Pre referral
b. Completion of antibiotic course in case referral is refused / not possible “OR” as advised by
treating physician
4. Kangaroo mother care at facility [E]
5. Full supportive care at block and district level [E]
a. NBSU at block level
b. SNCU at district level
6. Intensive care services (NICU) at regional level [A] for
a. Assisted ventilation
b. Surfactant use
c. Surgery
Package 6: Care beyond Newborn Survival
1. Screening for birth defects, failure to thrive and developmental delays [E]
2. Follow up visits of [E]
a. SNCU discharged babies till 1 year of age
b. Small and low birth weight babies till 2 years of age
3. Newborn screening [A]
4. Management of birth defects [E]
a. Diagnosis
 46

b. Treatment, including surgery

5. Follow-up of high-risk infants (discharged from SNCUs, and small newborns) for
a. Developmental delay
b. Appropriate management
Monitoring and Evaluation:
1. The Government of India has established a web-based tracking system (Mother and Child Tracking
System) to track every pregnant woman and child till the age of 2 years.
2. Core indicators (dashboard indicators) have been selected for monitoring, based on direct relevance
to the program.
Human milk banking
Introduction
A human milk bank is a centre to collect, screen, test, and store donor milk collected from healthy
lactating mothers. In India, these centres are called Comprehensive Lactation Management Centres
(CLMCs). The primary function of a CLMC is make sure that every child receives breast milk. A CLMC
performs three functions
1. It supports breastfeeding by helping new mothers breastfeed and resolve their lactation
issues.
2. It helps mothers to express milk for their own babies and to donate excess milk to the CLMC.
3. It tests, stores, and pasteurizes collected milk and feeds it to vulnerable babies who do not
have access to their mother’s milk due to unavoidable reasons.
Location of human milk banks
1. Human milk banks are primarily focused to provide donor milk to high risk newborns admitted in the
neonatal unit. Therefore, a location in close proximity or even inside the boundaries of neonatal unit
is desirable.
2. Non-government organizations (NGOs) taking care of abandoned babies can also have a human milk
bank in their facility.
The recipients
1. Absent or insufficient lactation: Mothers with multiple births, who can not secrete adequate
breastmilk for their neonates initially.
2. For babies of non-lactating mothers, who adopt neonates and if induced lactation is not possible. •
Abandoned neonates and sick neonates.
3. Temporary interruption of breastfeeding.
4. Infant at health risk from breastmilk of the biological mother.
5. Babies whose mother died in the immediate postpartum period.
The donors
1. A lactating woman who:
a. is in good health, good health-related behavior, and not regularly on medications
b. is willing to undergo blood testing for screening of infections; and
c. has enough milk after feeding her baby satisfactorily and baby is thriving nicely. Who cannot
donate?
2. A donor is disqualified who:
a. uses illegal drugs, tobacco products or nicotine replacement therapy; or
b. regularly takes more than two ounces of alcohol or its equivalent or three caffeinated drinks
per day; or
c. has a positive blood test result for HIV, HTLV, Hepatitis B or C or syphilis; or
d. is herself or has a sexual partner suffering from HBV, HIV, HCV and venereal diseases OR
either one has high risk behavior for contracting them in last 12 months; or
 47

e. has received organ or tissue transplant, any blood transfusion/blood product within the prior
12 months.
f. is taking radioactive or other drugs or has chemical environmental exposure or over the
counter prescriptions or mega doses of vitamins, which are known to be toxic to the neonate
and excreted in breastmilk; or
g. has mastitis or fungal infection of the nipple or areola, active herpes simplex or varicella
zoster infections in the mammary or thoracic region.
Processing
1. All batches of collected raw breastmilk should be refrigerated immediately till the serological report
comes negative.
2. Pasteurization is carried out by Holder’s method. Microbiological screening of donor milk is done
before (if there is no cost constraint), and as soon as possible after pasteurization.
Labeling and record keeping
1. Proper labeling at all levels is mandatory; from sterile container for collection of donation, pooling
vessel and pasteurization container to storage containers.
2. Record keeping at all levels should be meticulous for Donor Record File containing consent form,
donor’s and her child’s data, screening reports, pasteurization batch files, and for PDHM Disbursal
Record File containing relevant data, including recipient consent form.
Disbursal
Pasteurized donor human milk (PDHM) should be disbursed at physician’s requisition from NICU
physician after informed consent from the parents of the recipient. Preterm baby should preferably
get PDHM from preterm donors.

National iodine deficiency control programme

Introduction:
Iodine is an essential micronutrient required daily at 100-150 micrograms for normal human growth
and development. Deficiency of iodine can cause physical and mental retardation, cretinism,
abortions, stillbirth, deaf mutism, squint & various types of goiter. As per the surveys conducted in
India, the prevalence of Iodine Deficiency Disorders (IDDs) is more than 5% in many parts of India.
Control Programme:
Realizing the magnitude of the problem, the Government of India launched a 100 per cent centrally
assisted National Goiter Control Programme (NGCP) in 1962. In August, 1992 the National Goiter
Control Programme (NGCP) was renamed as National Iodine Deficiency Disorders Control
Programme (NIDDCP) and implemented in all the States/UTs for entire population.
Goal:
1. To bring the prevalence of IDD to below 5% in the country
2. To ensure 100% consumption of adequately iodated salt (15ppm) at the household level.
Objectives:
1. Surveys to assess the magnitude of Iodine Deficiency Disorders in the districts.
2. Supply of iodated salt in place of common salt.
3. Resurveys to assess iodine deficiency disorders and the impact of iodated salt after every 5 years in
the districts.
4. Laboratory monitoring of iodated salt and urinary iodine excretion.
5. Health Education and Publicity.
Achievements:
1. Over the years the Total Goiter Rate (TGR) in the entire country is reduced significantly.
 48

2. Production of iodized salt in the country reached to 65.00 lakh MT which is adequate to meet the
requirement of population.
3. The consumption of adequately iodated salt at household level has been increased from 51.1% (as
per NFHS III report 2005-06) to 71.1%.
4. Regulation of Food Safety and Standards (Prohibition and Restriction on Sales), Regulation, 2011
restricts the sale of common salt for direct human consumption unless the same is iodized.
5. National Reference Laboratory for monitoring of IDD has been set up at NCDC, Delhi. Four Regional
laboratories one each at NIN, Hyderabad, AIIH&PH, Kolkata, AIIMS and NCDC, Delhi have been set
up to conduct training, monitoring, quality control of salt and urine testing.
6. For effective implementation of NIDDCP 35 States/UTs have established IDD Control Cells in their
State Health Directorate. 35 States/UTs have set up State IDD monitoring laboratories in their
respective States/UTs.
Trivandrum development scale
1. The Trivandrum Developmental Screening Chart for children of 0-6 y was designed and developed at
the Child Development Centre, Government Medical College Campus, Thiruvananthapuram. Tool
items (51 in number) were chosen after discussions with experts like Pediatric Neurologists, Child
Psychiatrists, Clinical Psychologists, Developmental Pediatricians, Developmental Therapists, Speech
therapists and Epidemiologists. It includes adequate cognitive and motor milestones, which spread
over the first 6 y of life. It also includes items for testing hearing, vision, speech and language.
2. The range for each test item is represented by horizontal dark line based on the norms given in
developmental assessment scales, like TDSC (0–2 y), Bayley Scale of Infant Development (Baroda
norms), Developmental Assessment Scale for Indian Infants (DASSII) and Jamaica Portage guide to
Early Education.
3. For the test, the chronological age of the child is assessed first. Then a line is drawn vertically through
the chronological age of the child, horizontally marked in the bottom of the tool. The items with
upper limit ending to the left of the line are expected to be attained by the child normally. If any item
is not attained by the child by that age, that item delay is assumed for the child. Thus, the tool is
designed to be simple and no expertise is required, when compared with DDST. For the new tool
prematurity corrections are not done for calculating the chronological age of the child, as this would
make the tool complicated.
 49

4. TDSC (0–6 y) is a simple, convenient and valid screening tool, for identifying children of 0–6 y with
developmental delay in the community. This is a tool can be done in 10 min by a health worker with
just pen/pencil and some preliminary training to apply the tool.
5. This helps in community intervention programs and if needed refer the child at the earliest for
appropriate intervention to a nearby referral centre. This tool is not for assessing the developmental
age of the child and also not for a specific diagnosis of a developmental delay/disability.

Prenatal genetic testing

Indications:
1. Diagnostic procedures are used to identify fetal diseases when direct fetal treatment is possible, to
guide neonatal care, to deliver a viable but premature infant to avoid intrauterine fetal demise, or
when pregnancy termination is being considered.
2. Fetal assessment is also indicated when the reproductive history of the mother suggests the
presence of a high-risk pregnancy or a high-risk fetus.
Methods:
Methods of prenatal diagnosis can be divided into non-invasive and invasive techniques. Non-invasive
procedures Used for diagnosing congenital anomalies and risk assessment of given genetic disorders
1. Ultrasound: – routine obstetric ultrasound scan – high-resolution ultrasound scan and Doppler
studies – fetal heart echocardiography
2. Magnetic resonance imaging (MRI)
3. Maternal serum biochemistry testing (measurement of indicative enzymes in maternal blood serum)
Ultrasound:
Routine obstetric ultrasound scanning.
1. Performed by the obstetrician managing the pregnancy. Standards for normal pregnancies provide
for four scans carried out at: 11-14 weeks, 21-26 weeks, 27-32 weeks, and 40 week of gestation.
2. High resolution ultrasound scanning. Performed in any pregnancy with an increased risk of fetal
structural abnormalities, isolated or part of a genetic syndrome.
3. In recent years three-dimensional ultrasound (3D) and four-dimensional ultrasound (4D) have started
to play an increasing role in prenatal diagnosis. They can be applied in assessing facial features,
central nervous system abnormalities and skeletal defects.
4. Fetal US imaging may detect fetal growth abnormalities or fetal malformations.
5. Serial determinations of growth velocity and the head to-abdomen circumference ratio enhance the
ability to detect IUGR.
6. Real-time US may identify placental abnormalities (abruptio placentae, placenta previa) and fetal
anomalies such as hydrocephalus, NTDs, duodenal atresia, diaphragmatic hernia, renal agenesis,
bladder outlet obstruction, congenital heart disease, limb abnormalities, sacrococcygeal teratoma,
cystic hygroma, omphalocele, gastroschisis, and hydrops.
7. Real-time US also facilitates performance of needle-guided procedures (i.e. cordocentesis) and the
BPP by imaging fetal breathing, body movements, tone, and amniotic fluid volume.
8. Doppler studies: Detect abnormal blood flow in umbilical, placental, and fetal vessels that may be
suggestive of a genetic syndrome.
9. Fetal heart echocardiography: Performed at 18-23 weeks of gestation in the presence of an increased
risk of heart defect (for example: heart defect in a parent or sibling, abnormal routine ultrasound).
Magnetic Resonance Imaging.
MRI is used in combination with ultrasound, usually at or after 18 weeks’ gestation. MRI provides a
tool for examination of fetuses with large or complex anomalies, and visualization of the abnormality
in relation to the entire body of the fetus.
 50

Biochemistry testing (maternal serum markers)

First trimester:
1. Screening in the first trimester involves the measurement of PAPP-A (pregnancy associated plasma
protein A) and free -HCG (-human chorionic gonadotropin) levels in maternal serum. These
measurements are used in conjunction with ultrasound scanning that includes nuchal translucency
(NT) thickness of the nasal bone (NB). The detection rate of these combined methods is about 85-
90% in regard to trisomy 21 and 18.
2. New biochemical marker for Down and Edwards syndrome: ADAM 12 (A Disintegrin And
Metalloprotease 12) that can be used in the first trimester screening. Combining ADAM 12, PAPP-A,
β-HCG and NT measurements at 8-9 and 12-13 weeks of gestation increases the DR (detection rate)
to 97%, for a false positive rate of 1%.
Second trimester:
1. Second trimester maternal serum biochemistry (at 14-18 weeks of gestation) involves the “triple”,
“quadruple” (triple screen and inhibin A) and “integrated” screen.
2. Triple screen measures three markers
a. AFP (alpha-fetoprotein –made in the liver and GI tract of the fetus) It is excreted into fetal
urine, thus amniotic fluid, then transferred across placenta into maternal blood it increases
during 2nd trimester
b. hCG (human chorionic gonadotropin – made by the placenta peaks at 10 weeks and falls
from there) Pregnancy hormone tested for in pregnancy tests. Important marker for Down
syndrome (increased)
c. UE3 (unconjugated estriol) – made by the fetus, placenta, and mother; it increases
throughout pregnancy–found in both pregnant and nonpregnant women, but at different
levels)
3. With trisomy 21, second-trimester maternal serum levels of:
1. AFP and unconjugated estriol are about 25 percent lower than normal levels and
2. maternal serum hCG is approximately two times higher than the normal hCG level.
4. A test of levels of dimeric inhibin A (DIA) is sometimes added to the other three tests, under the
name “quad test”.
5. Other Uses of triple test:
Condition AFP hCG UE3
Open neural tube defects Increased _____________ _____________
Trisomy 18 Decreased decreased decreased
Down syndrome (trisomy 21) Decreased increased decreased
Invasive procedures
Invasive techniques include:
1. chorionic villus sampling (trophoblast cells analysis)
2. amniocentesis (amniotic fluid cells analysis)
3. cordocentesis (Percutaneous Umbilical Blood Sampling)
Chorion villi sampling (CVS)
1. A sample of the developing placenta is obtained transcervically or transabdominally at 8-11 weeks of
gestation under ultrasound guidance. A variety of diagnostic techniques can be employed on CVS
cells:
a. Karyotype analysis (classical and molecular cytogenetic methods) – detects all numerical and
many structural chromosome aberrations, including microdeletions that cause syndromes
such as Prader-Willi or William’s syndrome,
 51

b. Enzyme studies, when there is a risk of inborn errors of metabolism (phenylketonuria,

Gaucher disease, mucopolysaccharidosis, haemoglobinopathies such as thalassaemia),
c. DNA analyses in monogenic disease.
2. The risk to the pregnancy is about 2% (most frequently: miscarriage, infection, bleeding, limb
defects). The benefit of CVS is an early diagnosis and the chance to verify the results by other
invasive methods.
3. The following problems may arise in CVS:
a. placental mosaicism (confined to trophoblast tissue not fetal tissue),
b. contamination by maternal tissue.
Amniocentesis:
1. This can be performed usually done at 16- 18 weeks of gestation. A sample of about 15 ml of
amniotic fluid is obtained transabdominally under ultrasound guidance.
2. Methods of analysis include:
a. Karyotyping (cytogenetic as well as molecular cytogentic methods)
b. DNA analysis (monogenic disease diagnosis, such as congenital adrenal hyperplasia, cystic
fibrosis)
c. Biochemical studies:
i. Measurement of ache and AFP levels when considering neural tube defects
ii. Measurement of 17α-hydroprogesterone when a risk of congenital adrenal
hyperplasia
iii. Inborn errors of metabolism diagnosis (mucopolysaccharidosis, familial
hypercholesterolaemia, 51onographic51in51rophy, homocysteinuria, maple syrup
urine disease)
d. The risk of amniocentesis is around 0.5-1% and it includes miscarriage, transient amniotic
fluid leakage and intrauterine infection.
Cordocentesis (Percutaneous Umbilical Blood Sampling)
1. A sample of 0.5-1 ml fetal blood is obtained from the umbilical vein (close to the placenta) usually at
18-23 weeks of gestation under ultrasound guidance. The blood sample can be used for genetic and
biochemical studies, including chromosomal analysis and monogenic disease diagnosis
(phenylketonuria, cystic fibrosis, Duchenne muscular dystrophy).
2. It is also possible to detect haemoglobinopathies, immunological deficiency syndromes (ataxia-
teleangiectasia) and intrauterine infections (toxoplasmosis, rubella, cytomegaly).
3. The risk is estimated to be around 2% with fetal death, premature birth, bleeding (usually transient)
and fetal bradycardia (usually short lasting) being the most frequent complications.

Infant and young child feeding (IYCF)

1. In 2002, UNICEF and WHO adopted the Global Strategy for IYCF. The plan was created to raise awareness
of the effects that feeding habits have on infants' and young children's survival, growth, and
development, as well as their nutritional status. It is imperative that every health professional possess
the Global Strategy's tenets to protect, promote, and support appropriate IYCF
2. IYCF is a set of well-known and common recommendations for appropriately feeding newborns and
children under two years of age. It includes:
a. early initiation of breastfeeding,
b. EBF for the first six months, and
c. complementary feeding after six months.
3. Early initiation of breastfeeding refers to starting to breastfeed as soon as possible after birth, ideally
within the first hour, for all normal newborns, including those delivered via cesarean section. Since
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colostrum, the milk secreted during the first two to three days of life has a high concentration of
immune-system-boosting cells and immunoglobulins, it should be fed to the newborn instead of being
thrown out. The newborn should not be given any prelacteal fluid.
4. EBF means that during the first six months of life, infants should only be breastfed by their mother, a wet
nurse, or expressed breast milk; they should not be given any other liquids, solids, or even water. The
only exceptions are when oral rehydration solutions, oral vaccinations, vitamin and mineral supplements,
or medications are administered.
5. When a child reaches the age of six months, complementary feeding refers to adding breast milk to solid
or semisolid food. Breast milk is no longer adequate to meet an infant's nutritional needs after six
months of life. Nonetheless, newborns are susceptible when they go from exclusively breast milk to
receiving additional feedings beyond breastmilk. Breastfeeding must continue along with suitable
supplemental feeding to guarantee that a young child's nutritional needs are satisfied. It is appropriate to
use the term "complementary feeding" rather than "weaning".

Hidden hunger
Hidden hunger (micronutrient deficiency) is a form of undernutrition that occurs when intake and absorption
of
vitamins and minerals (such as zinc, iodine, and iron) are too low to sustain good health and development.
Factors that contribute to micronutrient deficiencies include poordiet, increased micronutrient needs during
certain life stages, such as pregnancy and lactation, and health problems such as diseases, infections, or
parasites.
While clinical signs of hidden hunger, such as night blindness due to vitamin A deficiency and goitre from
inadequate iodine intake, become visible once deficiencies become severe, the health and development of a
much larger share of the population is affected by less obvious “invisible” effects. That is why micronutrient
deficiencies are often referred to as hidden hunger.
Hidden hunger afflicts more than 2 billion individuals, or one in three people, globally. Its effects can be
devastating, leading to mental impairment, poor health, low productivity, and even death. Its adverse effects
on child health and survival are particularly acute, especially within the first 1,000 days of a child's life, from
conception to the age of two, resulting in serious physical and cognitive consequences. Even mild to
moderate deficiencies can affect a person's well-being and development. In addition to affecting human
health, hidden hunger can curtail socioeconomic development, particularly in low and middle income
countries.
The nature of the malnutrition burden facing the world is increasingly complex. Developing countries are
moving from traditional diets based on minimally processed foods to highly processed, energy-dense,
micronutrient-poor foods and drinks, which lead to obesity and diet-related chronic diseases. With this
nutrition transition, many developing countries face a phenomenon known as the “triple burden” of
malnutrition-undernourishment, micronutrient deficiencies, and obesity. In higher income, more urbanized
countries, hidden hunger can co-exist with overweight/ obesity when a person consumes too much dietary
energy from macronutrients such as fats and carbohydrates. While it may seem paradoxical, an obese child
can suffer from
hidden hunger.
The consequences of hidden hunger
1. Physical health: anemia, night blindness, osteoporosis, and cardiovascular disease.
2. Cognitive development: can impair cognitive functions, leading to poorer school performance and
learning skills.
3. Pregnancy: negatively impact pregnancy and embryonic-foetal neurodevelopment.
4. Birth deformities: A lack of folic acid in a pregnant woman's diet can lead to birth deformities.
 53

5. Chronic disease: Children who experience hidden hunger in early childhood are more likely to suffer
from chronic disease later in life.
6. Work productivity: Adults with hidden hunger may have lower work productivity and economic
output.
7. Healthcare costs: Hidden hunger can lead to higher healthcare costs for both individuals and the
nation.
8. National GDP: Hidden hunger can lead to significant losses in national GDP.
9. Intergenerational cycle: Hidden hunger in mothers can lead to low birth weight babies, perpetuating
the cycle of malnutrition.
10. Hidden hunger is difficult to identify because many of its consequences, such as lower cognitive
function, develop over a lifetime and are hard to attribute to a specific deficiency.
Steps taken to address Hidden Hunger in India include:
1. Fortification of Staple Foods: The government has promoted fortifying staple foods like wheat flour,
rice, and edible oils with essential vitamins and minerals to improve their nutritional value.
2. National Nutrition Mission (Poshan Abhiyaan): The Poshan Abhiyaan aims to reduce malnutrition,
including hidden hunger, through targeted interventions, awareness campaigns, and behavior change
communication.
3. Integrated Child Development Services (ICDS): The ICDS program provides supplementary nutrition
to pregnant women, lactating mothers, and children to address nutritional deficiencies.
4. Mid-Day Meal Scheme: The Mid-Day Meal Scheme in schools offers nutritious meals to children,
addressing hidden hunger and improving attendance and learning outcomes.
5. Promotion of Nutrient-Rich Foods: The government encourages the consumption of nutrient-rich
foods like fruits, vegetables, pulses, and dairy products through public awareness campaigns.
6. Food Fortification Laws: India has mandated fortifying certain food items like salt with iodine to
combat micronutrient deficiencies.
7. National Food Security Act (NFSA): The NFSA aims to provide subsidized food grains to vulnerable
populations to ensure food security and combat hidden hunger.
8. Nutrition Education and Awareness: Various campaigns and programs are conducted to educate
communities about the importance of a balanced diet and proper nutrition.
9. Multi-Sectoral Approach: Efforts to address hidden hunger involve collaboration between various
sectors, including health, agriculture, education, and women and child development.

Screening test and validity

Introduction
Screening is defined as a search made for detecting the hidden disease among apparently healthy
individuals in the community, by means of rapidly applied test. Thus, screening test divides the
apparently healthy population into two groups—those probably having the disease/risk factor and
those probably not having the disease / risk factor.
Types of Screening
6) Mass screening,
7) High-risk screening,
8) Multipurpose screening,
9) Multiphasic screening and
10) Opportunistic screening.
Mass Screening
 54

This is the screening of the entire population of an area for a disease, for example, night blood smear
examination for microfilariae of every individual in hyperendemic area of filariasis. However, this is
not an useful preventive measure unless it is backed up by the treatment and follow-up.
High-risk Screening
This is the screening of only those groups of population, who are at a high-risk of the disease and not
of the entire population. This is also called ‘Selective screening or Targeted screening’. For example,
screening of women of low socioeconomic class for CaCx, of all obese people for hypertension or
diabetes, of sex-workers for HIV, of family contacts of infectious pulmonary tuberculosis or
lepromatous leprosy, etc.
Multipurpose Screening
This is the screening of a group of population by application of two or more tests, at one time to
detect more number of diseases. For example, screening of pregnant mothers with blood for Hb
percent, VDRL, Elisa for HIV, surface antigen for HBV, for blood grouping and Rh-typing, urine for
albumin, sugar and microscopy; screening all school children with height and weight, vision defects,
hearing defects, dental defects, congenital defects; screening of all elderly persons for diabetes,
hypertension, hearing defects, cancer, cataract, refractive error, glaucoma, etc.
Multiphasic Screening
This is the screening of the population by applying different tests in different phases, for the
diagnosis of one disease. For example, the whole population of an area is screened by testing urine
for sugar. Those who are positive for glycosuria are subjected for fasting blood sugar level (FBS).
Those who have FBS > 120 mg/dL are subjected for oral glucose tolerance test (OGTT) to find out
true diabetics.
Opportunistic Screening
This is the screening of a patient, who consults the doctor for some other purpose. This is also called
‘Case finding screening’.
Validity of screening
4) Validity of a test means the ability of a test to correctly identify those with disease from those
without the disease among the apparently healthy people. For example, oral glucose tolerance test is
a more accurate (valid) test than examining urine for sugar. Similarly, Treponema pallidum
immobilization test is more valid than blood for VDRL test.
5) Validity has got two components—sensitivity and specificity; both the components can be
determined by applying the screening test on two groups of persons, one group having the disease
and another group not having the disease and expressed as percentages.
6) The relationship between a screening test result and the occurrence of disease is interpreted as
follows:
Interpretation
5) True positive (a) = Means those who have the disease and the test result is also positive.
6) False positive (b) = Means those who do not have the disease but the test result is positive.
7) False negative (c) = Means those who have the disease but the test result is negative.
8) True negative (d) = Means those who do not have the disease and the test result is also negative.
Evaluation of a screening test for the validity (Expressed in percentages).
The following indicators are used to evaluate the screening test:
Sensitivity:
3. It is the ability of a test to correctly identify those having the disease, i.e. true positives. (i.e.
percentage of diseased persons, showing the test result positive).
Sensitivity = a ×100
a+ c
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4. Sensitivity of a screening test is 90 percent means, 90 percent of the diseased persons are correctly
identified as ‘True positives’ and remaining 10 percent of diseased persons are wrongly identified as
not having the disease, because the test is negative (False negatives).
Specificity:
5. If is the ability of the test to correctly identify those not having the disease, i.e. true negatives. (i.e.
percentage of non-diseased persons, showing the test result negative)
Specificity = d ×100 .
b+d
6. Predictive value of a test: It means the diagnostic power of a test. The test has 2 results, positive and
negative.
a. Predictive value of a positive test: It means the probability of an individual really having the
disease, if the test result is positive. (i.e. percentage of positives probably having the
disease.
Predictive value of a positive test = a × 100.
a+b
b. Predicted value of a negative test: It means the probability of an individual really not having
the disease, if the test result is negative. (i.e. percentage of negatives probably not having
the disease)
Predicted value of a negative test = d × 100.
c+d
7. False positives: These are the percentage of non-diseased persons wrongly identified as having the
disease, because the test result is positive.
False positives = b × 100
b+d
8. False negatives: These are the percentage of diseased persons wrongly identified as not having the
disease, because the test result is negative.
False negatives = c × 100.
a+c
Example
A new screening for a certain disease was administered to 480 persons, 60 of whom are known to
have the disease. The test was positive in 50 of the persons with the disease as well as in 20 persons
without the disease. Evaluate the screening test by all the measures.
4. Sensitivity (True positive) = a/a+c × 100 = 50/60 × 100 = 83.33%.
5. Specificity (True negative) = d/b+d × 100 = 400/420 × 100 = 95.24%.
6. Predictive value of a positive test = a/a+b × 100 = 50/70 × 100 = 71.43%.

Emergency contraception
Estrogen, Postcoital Pills (Emergency Oral Contraception)
1. Emergency oral contraception can prevent pregnancy. Therefore, often it is called ‘Morning after’
contraception. This method should not be used in place of family planning methods. Any woman can
adopt this method if she is not already pregnant, to prevent unplanned pregnancy, only as an
emergency under the following circumstances:
a. Unprotected intercourse
b. Rape, sexual assault, incest
c. Failure of contraceptive method such as rupture of condom, displacement of IUD, missing
two or more mini pills
d. Premature ejaculation among couples practicing coitus interruptus.
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2. This emergency method is recommended within 48 to 72 hours of unprotected intercourse. They act
by stopping ovulation or by interfering with implantation of the ovum. Different methods are as
follows:
a. High dose progesterone
b. High dose estrogens
c. Estrogen—progesterone combination.
High Dose Progesterone
Each of these contains 1.5 mg levonorgestrel. One pill to be taken orally, preferably within 12 hours
and not later than 72 hours of unprotected sex. It prevents ovulation. If ovulation has already
occured, it prevents fertilization of ovum. If fertilization has already occured, it prevents implantation
in the endometrium. It is ineffective, if the pregnancy has already occured. It is marketted as ‘i-pill’. It
does not protect from STD/HIV. Nausea, vomiting, headache, breast tenderness are common side
effects. It will stop after 1 or 2 days.
High Dose Estrogens
These are:
a. Diethylstilbestrol (DES) 50 mgm a day for 5 days.
b. Ethinyl estradiol 05 mgm a day for 5 days.
c. Estradiol benzoate 12.5 mgms combined with estradiol phenyl propionate 10.0 mgm.
Failure rate is less than 1 percent. Side effects are high and severe because of high doses of estrogen.
Therefore, this old method is replaced by a safer and new method, i.e. Yuzpe method.
Estrogen—Progesterone Combination (Yuzpe Method)
In 1977, Yuzpe and Lancee showed that a combination of 100 mgm of estrogen and 1 mgm of
progestogen, in a single dose rendered the endometrium out of phase. This method consisting of
consuming either 8 low dose combined oral contraceptive pills (Mala-D) (4 as soon as possible
followed by another 4 after 12 hours) or 4 standard dose combined pills (Mala-N) (2 pills followed by
another 2-pills after 12 hours).
Merits: Simple, safe, cheap and readily available method.
Demerits: Due to high doses of estrogen. This method is ineffective, if the implantation of ovum has
already occurred.
Failure rate is 0.2 to 2.0 percent.
Recent advances
1. Danazol: It is a progestogen only with antigonadotrophic activity. It prevents implantation by making
unfavorable endometrium. Dose—2 doses of 400 mgm each at 12 hours interval. This is more
effective than Yuzpe regimen.
2. Mifepristone: It is antiprogesterone. It prevents ovulation when given in early proliferative phase and
hinders the development of endometrium if given in the luteal phase, (i.e. within 72 hours of
unprotected sex). Dose—600 mg stat. This is more effective than Yuzpe regimen and Danazol.
Mechanical method of emergency contraception:
This consists of insertion of copper IUD within 3 to 5 days of unprotected intercourse. It prevents
implantation due to endometrial changes and also possibly it has embryotoxic effect by copper ions.
Additional advantage is that it provides contraceptive protection for few more years. This is
particularly useful when hormonal pills are contraindicated. This is contraindicated in women who
are at risk of STD because of rape. This is more effective than hormonal method as an emergency
method.
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Approach to hearing impairment

Hearing Loss
Hearing loss in children may be congenital or acquired. Based on pathology, hearing loss is
categorized as conductive, sensorineural or mixed. Early detection of hearing loss in children is
important as untreated hearing loss interferes with development of speech, language and cognitive
skills.
Conductive Hearing Loss
1. Any pathology that interferes with the conduction of sound through the ear canal, tympanic
membrane or middle ear ossicles may cause conductive hearing loss. Hearing loss is usually acquired
and mild to moderate in severity.
2. Common causes include otitis media with effusion, tympanic membrane perforation,
tympanosclerosis and cholesteatoma. Less commonly, conductive hearing loss is congenital,
associated with congenital ossicular fixation or discontinuity and atresia of the ear canal. Hearing loss
may be associated with middle ear abnormalities, e.g. Apert, Crouzon and Treacher Collins
syndromes.
Sensorineural Hearing Loss
1. Sensorineural hearing loss is caused by pathology in the cochlea, auditory nerve or central auditory
pathway. Congenital and acquired hearing loss is equally prevalent. The most common cause of
acquired sensorineural hearing loss is meningitis; other causes are prematurity, hyperbilirubinemia,
perinatal hypoxia, acquired immunodeficiency syndrome, head trauma and medications (e.g.
aminoglycosides, loop diuretics).
2. The chief etiology of congenital hearing loss is intrauterine infections (e.g. TORCH, syphilis). Almost
30% of congenital hearing loss is associated with one of 300 inherited disorders, including Pendred
syndrome (euthyroid goiter), Jervell and LangeNielsen syndrome (prolonged QT waves, syncope),
Usher syndrome (retinitis pigmentosa and blindness), Alport syndrome (microscopic hematuria and
renal failure), branchio-oto-renal syndrome, neurofibromatosis and Waardenburg syndrome. Over 65
genes are associated with inherited hearing defects. Mutations in GJB2, encoding for connexin 26
(expressed in the inner ear and involved in cochlear homeostasis) account for one-half of patients
with autosomal recessive non-syndromic hearing loss.
Screening for Hearing Loss
1. Significant hearing loss is present in 1-3 per 1000 newborns, particularly in babies requiring neonatal
intensive care. Hearing loss has significant implications for development of speech, language and
cognitive skills.
2. Effective hearing aids and cochlear implants are now available that, if applied early in life and
supplemented with auditory training, can lead to near-normal hearing, good acquisition of speech
and language, and integration into normal schooling.
3. Hence, most countries as well as the Indian Academy of Pediatrics recommend universal screening
for hearing loss in newborn period. An important initiative in infant hearing screening and
intervention program is the '1-3-6' guideline. This recommends screening all newborns for hearing
loss by 1 month of age, completing secondary diagnostic testing for infants who fail the first
screening by 3 months, and ensuring early intervention for diagnosed hearing loss by 6 months,
enabling language and social development in line with physical development.
4. Screening in Older Children
Indications for hearing screening in older children are parental concern for hearing or speech, poor
language development or decline in language skills, ear infections, difficulty in understanding
conversation or inappropriate response to commands. Examination includes otoscopy with attention
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to middle ear pathology. Doubtful cases require referral for audiologic evaluation. Techniques that
assess hearing sensitivity are selected based on child's age and ability to cooperate with testing.
4. Indications for continued hearing monitoring despite normal hearing on neonatal screening
1. Caregiver concern regarding hearing, speech, or developmental delay
2. Family history of childhood hearing loss
3. Neonatal intensive care for >5 days or any of the following: Extracorporeal membrane
oxygenation; assisted ventilation; exposure to ototoxic antibiotics or loop diuretics;
hyperbilirubinemia requiring exchange transfusion
4. In utero infections (CMV, rubella, syphilis, herpes, toxoplasmosis)
5. Findings of a syndrome associated with hearing loss
6. Postnatal infection known to cause hearing loss (e.g. meningitis)
7. Syndromes associated with progressive hearing loss (e.g. neurofibromatosis)
8. Neurodegenerative disorders ( e.g. Hunter syndrome, Friedreich ataxia)
9. Head trauma
10. Recurrent or persistent (> 3 months) otitis media with effusion
11. Chemotherapy or radiation to head and neck
Management of Hearing Loss
1. Management of hearing loss is based on the extent of deficit and the underlying pathology. For mild
to moderate conductive hearing loss, options include tympanostomy tube for otitis media with
effusion, tympanoplasty for tympanic membrane perforations, mastoidectomy and tympanoplasty
for cholesteatoma and canaloplasty for canal atresia.
2. Conventional hearing aid, bone conduction hearing aid or middle ear implant are considered in
patients with conductive hearing loss, if the pathology cannot be surgically corrected. Treatment of
mild sensorineural hearing loss may consist simply of preferential seating in school. Unilateral or
bilateral hearing aid usage is advised for mild to moderate sensorineural hearing loss, while children
with severe to profound loss who do not benefit significantly from hearing aid are considered for
cochlear implantation.
3. Patients in whom cochlear implants are not feasible are taught sign language and enrolment in deaf
education programs.
Pediatric Cochlear Implantation
1. A cochlear implant directly stimulates the residual cochlear nerve cells in the spiral ganglion
(cochlea). The US FDA approves cochlear implantation in adults with bilateral severe to profound
(>70 dB hearing loss) sensorineural hearing loss who have poor speech discrimination and fail
hearing aids.
2. Cochlear implantation is advised for children with severe to profound sensorineural hearing loss with
unsatisfactory benefit from a trial of hearing aid use for 3-6 months.
3. Evaluation before surgery includes computed tomography and magnetic resonance imaging to assess
anatomic anomalies and confirm the presence of cochlear nerve. Multielectrode implants that
provide information across various frequencies are positioned sequentially along the cochlea to
allow sound to be coded and transmitted for the entire sound spectrum.

Stuttering
(Childhood-Onset Fluency Disorder)
Definition
1. Developmental stuttering is a childhood speech disorder that is not associated with stroke, traumatic
brain injury, or other possible medical conditions and that interrupts the normal flow of speech
through repeated or prolonged sounds, syllables, or single-syllable words.
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2. Multiple nonspeech features include movements of the head (head turning or jerking), face (eye
blinking/ squinting, grimacing, opening or tightly closing the jaw), and neck (tightening) and irregular
inhalations and exhalations.
3. In the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), the term
stuttering has been removed from the diagnostic classification, and the disorder is referred to as
childhood onset fluency disorder.
Epidemiology
It appears that 0.75–1% of the population is experiencing this condition at any one time. The mean
age of onset is 2-4 yr, and most children stop stuttering within 4 yr of onset. Male : female ratio
favors males.
Genetics: stuttering appears to be a polygenic condition, and several genes increase susceptibility.
Etiology
Brain structure and function abnormalities found in stutterers include deficits in white matter in the
left hemisphere, overactivity in the right cortical region, and underactivity in the auditory cortex.
Abnormal
basal ganglia activation has also been identified among stutterers.
Comorbidities
1. Speech sound (phonologic) disorders are the most commonly reported comorbidities
2. language disorders occur in some
3. Higher rates of psychopathology, specifically social anxiety and generalized anxiety disorder are seen
among adolescents who stutter.
4. Children who stutter have consistently been found to be bullied more than peers.
Developmental progression
1. Onset of stuttering typically occurs between 2 and 4 yr of age. Symptoms may ebb and flow,
including disappearing for weeks before returning, especially among young children. From 40–75% of
young children who stutter will stop spontaneously, typically within months of starting.
2. Risk factors for persisting include stuttering for >1 yr, continued stuttering after age 6 yr, and
experiencing other speech or language problems.
Treatment
1. There is no cure for stuttering but behavioral therapies are available.
2. Preschool or older children with stuttering should be referred to a speech pathologist. Therapy is
most effective if started during the preschool period
3. Parents should not yell at the child, but should calmly praise periods of fluency.

Truancy
1. Truancy is defined as a “deliberate absence from school without parental knowledge”. Truancy may
represent disorganization within the home, caretaking needs of younger siblings, developing conduct
problems, or emotional problems including depression or anxiety.
2. When truancy occurs in younger children, there are usually psychosocial concerns with the parents or
adult caretakers in the home that prevent them from following through with the regular demands for
their children. It is important to consider whether parents are struggling with housing and food
insecurity, making school attendance less of a priority.
3. Parents with intellectual disability or their own mental health or substance abuse problems may become
overwhelmed with managing the home and caring for their children, and thus might not consistently
ensure their child gets to school. Also, children might decide to remain at home to take care of parents
who are impaired.
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4. Truancy is more common in older children and can be a function of multiple factors, including but not
limited to learning difficulties, social anxiety, depression, traumatic exposure, bullying, peer pressure,
and substance use. In any of these cases, the child should be referred for further evaluation to assess the
barriers to returning to school.
5. School environment: Factors such as the school's environment, administration, and teaching can
contribute to truancy. Students may feel isolated or alienated in large classrooms.
6. Teacher-student relationship: Teacher-student relationships can be a factor in truancy.
7. Student variables: Students' attitudes towards school, physical and mental health, substance abuse, and
perception of self can all contribute to truancy.
8. Family: Factors such as parental involvement, family support, and household issues can contribute to
truancy.
9. Peer pressure: Bullying and peer pressure can contribute to truancy.
10. School policies: Ineffective discipline policies and inadequate guidance and counseling services can
contribute to truancy.
11. Curriculum: A lack of engaging curriculum can contribute to truancy.
12. Socioeconomic status: Socioeconomic status can contribute to truancy.
13. Awareness of attendance rules: Unawareness of attendance rules can contribute to truancy.
14. Contradictory views on education: Contradictory views on the importance of education among parents
can contribute to truancy
15. Best practices for dealing with truancy resulting from school avoidance and anxiety include addressing
the underlying psychological symptoms causing the school avoidance and empowering parents, children,
and school staff to work on a consistent plan for a return to school. Younger children may threaten
running away out of frustration or a desire to “get back at” parents. Older children who run away are
almost always expressing a serious underlying problem within themselves or their family, including
violence, abuse, and neglect. Adolescent runaways are at high risk for substance abuse, unsafe sexual
activity (e.g., sexual exploitation), and other risk-taking behaviors. Youth exhibiting truancy or running
away should be referred for a mental health evaluation.

TAEI- Tamilnadu accident and emergency care initiative

Introduction
TAEI is a government initiative in Tamil Nadu that aims to reduce the number of deaths and illnesses in
the state. TAEI facilities are equipped with advanced infrastructure and efficient staff. The initiative also
includes training for emergency department staff on basic care and primary resuscitation.
Aims:
4. To Initiate and Maintain and Health Care Setup to provide Comprehensive Service to All Medical and
Surgical Emergencies aimed at Reducing the Mortality and Morbidity
5. To Develop and Implement Protocols for Uniform and High Quality Care in Emergency Departments
across All Hospitals
6. To Develop and Implement Protocols for effective Management to Reduce Mortality and Morbidity
associated with Non Communicable Diseases, especially (1) Accidents and Trauma (2) Myocardial
Infarction (3) Cerebro Vascular Accidents (Strokes), (4) Burns (5) Poisoning (6) Paediatric Emergencies
Objectives
12. To halve the number of deaths and injuries from road traffic accidents by the year 2020 globally.
13. To achieve halve the number of deaths (8500) and injuries from road traffic accidents by year 2023 in
Tamil Nadu State.
14. To Standardize Managements of All Medical and Surgical Emergencies into predefined and distinct
stages and to have specific and clear protocols for management in each stage
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15. To Triage Patients into Red, yellow and Green Categories and to institute appropriate management
16. To ensure definitive treatment for the injured within the Golden Hour and to have “Time Norms” for
procedures in the Emergency Department
17. To Start the Process of Rehabilitation as early as possible
18. To identify and designate TAEI Centres as Level-1, Level-2, Level-3 centres with Assured Care in Each
Centre based on the level
19. To Augment the Hard (Civil Works, Equipments, Consumables, Drugs) and Soft (Human Resources-
New Posts as well as Filling Vacancies, Training) Infrastructure in these centres as per need and
implementation of Standard Operating Procedures in these centres
20. To install the Basic Life Support Ambulances Level -IV on an evidence based approach along the
Highways and Advanced Life Support Ambulance at Trauma Care Facilities for inter facility transfer
and expand the ECC facilities provided already to all high accident density areas.
21. To initiate the development of a state-wide referral network with both public and private hospitals
through empanelment of CMCHIS Insurance
22. To establish “State Trauma Surveillance Centre” with real time reporting of accident & trauma cases
for the Trauma Registry which will provide evidence based decision for policy formulation on road
safety, injury preventive interventions with component for improving of quality care and better out
comes and rational utilization of resources and Continuous physical & financial monitoring of the
programme.
Expected outcome
(TAEI) is expected to have the following tangible results.
8. Emergency Room uniformly standardized in each facility of the state
9. Standardised Treatment Protocol and guidelines
10. Color Codes for Triage
11. Assured service like CEmONC, NICU
12. Improved Quality of Care
13. Reduction in Mortality
14. Reduction in Morbidity

Cochlear implant
11. Infants and young children with profound congenital or prelingual onset of deafness have benefited from
multichannel cochlear implants
12. Cochlear implants are systems which combine internal (surgically implanted) and externally worn
components. These implants consist of four main components: the externals, which include a
microphone, a minicomputer sound (speech) processor, a transmitter; and the internal, an electrode
array.
13. These implants bypass injury to the organ of Corti and provide neural stimulation through the digitization
of auditory stimuli into digital radiofrequency impulses. Specifically, sound is initially detected by the
microphone and then is processed by the speech processor. The speech processor is programmed by an
audiologist to implement (the manufacturer's) proprietary speech processing strategies that are highly
sophisticated manipulations of the input signal.
14. Signals from the speech processor are transmitted across the skin by an FM signal to the internal
receiver, which converts these signals to electrical impulses. Finally, these electrical impulses are sent to
the electrode array located in the cochlea, where electrical fields are created that act on the cochlear
nerve. This is in contrast to the transmission of sound in a healthy ear, which involves the transmission of
sound vibrations to the hair cells of the cochlea, the release of ions and neurotransmitters in the cochlea,
and the transmission of neural impulses to the cochlear nerve and then the brain.
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15. Surgical implantation is done under general anesthesia and involves mastoidectomy and widening of the
facial recess. The approach to the cochlea is through the facial recess. After fastening the internal
stimulator package in the mastoid process, the cochlea must be opened in order to insert the electrode
array, which is most commonly done through an opening made in the round window. Care is taken to
avoid contamination of the cochlear fluids by bone dust or blood. After the cochlea is closed, generally
with fascia, the wound is closed.
16. An audiologist performs testing in the operating room to verify the functional integrity of the implanted
device. These electrophysiologic responses from the VIII nerve are critical to determining a starting point
for programming the external device after the wound has healed. A plain x-ray is often performed in the
operating room as well to document placement of the array in the scala tympani.
17. The healing process following surgery is approximately 3-4 wk for a child. During this time, the child
cannot hear. When the child is brought in for the first stimulation using the external equipment,
programs are developed that provide first access to sound. The methods to create the programs entail a
combination of electrophysiologic measures and behavioral testing that is similar to the pediatric
audiologic assessments described above. The initial programs are a starting point, followed by
modifications and enhancements that are based on the parents’ and audiologist's observations of
changing auditory awareness and vocalization.
18. Speech and language therapy is necessary to stimulate language and to teach parents skills to support
speech development.
19. A serious possible complication of cochlear implantation is pneumococcal meningitis. All children
receiving a cochlear implant must be vaccinated with the pneumococcal polyvalent vaccine PCV13, and
rates of pneumococcal meningitis have declined considerably since implementation of the vaccine.
20. Cochlear implantation before age 2 yr improves hearing and speech, enabling more than 90% of children
to be in mainstream education.

Prevention of diarrheal disease

Prevention of diarrhea and its nutritional consequences should receive major emphasis in health education.
The three main measures to achieve this are:
Proper nutrition:
1. Since breast milk offers distinct advantages in promoting growth and development of the infant and
protection from diarrheal illness, its continuation should be encouraged.
2. Exclusive breastfeeding may not be adequate to sustain growth beyond the first 6 months of life.
Therefore, supplementary feeding with energy-rich food mixtures containing adequate amounts of
nutrients should be introduced by 6 months of age without stopping breastfeeding.
Adequate sanitation:
1. Improvement of environment sanitation, clean water supply, adequate sewage disposal system and
protection of food from exposure to bacterial contamination are effective long-term strategies for
control of all infectious illnesses including diarrhea.
2. Three 'Cs; clean hands, clean container and clean environment are the key messages. Mother should
be properly educated about this. Complementary foods should be protected from contamination
during preparation, storage, and at the time of administration.
3. Household water treatment methods that are effective in reducing diarrhoea and storage of water in
containers that do not allow manual contact are recommended for people with HIV and their
households.
4. Proper disposal of faeces in a toilet or latrine or at a minimum, by burial in the ground is
recommended for people with HIV and their households.
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5. Promotion of hand-washing with soap after defaecation, handling of human or animal faeces and
before food preparation and eating, with the provision of soap.
6. Use of sanitary latrines
Vaccination:
1. Effective vaccines are now available against the commonest agent, i.e. rotavirus and their use might
be an effective strategy for preventing acute diarrhea.
2. Measles vaccination.
Zinc and Vit. A Supplementation
1. Zinc deficiency has been found to be widespread among children in developing countries. Intestinal
zinc losses during diarrhea aggravate pre-existing zinc deficiency. Zinc supplementation is now part of
the standard care along with ORS in children with acute diarrhea. It is helpful in decreasing severity
and duration of diarrhea and also risk of persistent diarrhea.
2. Zinc is recommended to be supplemented as sulfate, acetate or gluconate formulation, at a dose of
20 mg of elemental zinc per day for children >6 months for a period of 14 days.
3. Vit A: Give vitamin A to all children > 6 months of age every 6 months (100 000 IU for 6–12 months
and 200 000 IU for ≥12 months) up to 5 years of age.

Current strategies for polio eradication in India

WHO definition of AFP:
1. Flaccid paralysis of less than 4 weeks duration in children less than 15 years of age will be
considered as a case of AFP
Acute: rapid progression of paralysis from onset to maximum paralysis (hours to days)
Flaccid: loss of muscle tone, “floppy” – as opposed to spastic or rigid
Paralysis: weakness, loss of voluntary movement
Differential diagnoses of AFP
1. Anterior horn cell:
1. Viral: poliomyelitis
2. Immune mediated: acute transverse myelitis
2. Nerve trunk:
1. Immune mediated: Guillain-Barre
2. Toxin: Diphtheria; porphyria
3. Traumatic: IM injections
3. Neuromuscular junction:
1. Tick toxin
2. Botulinum
4. Muscles:
1. Myositis
5. Metabolic:
1. Familial periodic paralysis: autosomal recessive; abnormal K levels; episodic paralysis

AFP SURVEILLANCE
WHO definition for polio surveillance:
Flaccid paralysis of less than 4 weeks duration in children less than 15 years of age will be considered
as a case of AFP and should be investigated for isolation of polio virus and confirmation of diagnosis.
This is the joint responsibility of PHC/Deputy Director of HS/SMO (Surveillance MO)
Background rate
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1. At least one case of AFP (excluding polio) occurs annually for every 100,000 children less than 15
years of age. This is referred to as the “background” rate of AFP among children.
2. The non-polio causes of AFP including (but not limited to):
1. Guillian-Barré Syndrome (GBS),
2. Transverse Myelitis and
3. Traumatic Neuritis account
3. Sensitive surveillance for AFP must be able to detect a minimum of 1 case per 100,000 children
less than 15 years of age.
The Purpose of AFP Surveillance
1. AFP surveillance helps to detect reliably areas where poliovirus transmission is occurring.
2. AFP surveillance helps us to identify areas of priority for focusing immunisation activities.
3. It is the most reliable tool to measure the quality and impact of polio immunisation activities.
4. It is necessary for polio free certification from WHO
AFP CASE INVESTIGATION
1. Case Notification: all health facilities, clinicians and other practitioners are required to notify AFP
cases immediately to the District Immunization Officer (DIO), by the fastest available means
2. Case Investigation:
1. All cases should be verified and investigated within 48 hours of notification
2. Collect two stool samples from the child at a minimum interval of 24 hours
within 14 days; from late-reported cases for up to 60 days
3. Outbreak Response Immunization: is organized in the community and performed as soon as
possible.
4. Search: The investigation team searches for additional AFP cases in the community called “hot
cases”
5. Stool sample: the specimens to arrive at the laboratory within 72 hours of dispatch in cold chain
6. Lab report: isolation result is reported to the surveillance program no more than 28 days from
the time the specimen by lab
7. Sixty day follow-up: is done between the 60th and 90th day in certain categories of AFP cases to
determine the presence/ absence of residual paralysis
8. Within 90 days of paralysis onset, all cases should undergo final classification as confirmed
polio, non- polio AFP or compatible with poliomyelitis.
1. An AFP case is “confirmed” as polio only by the isolation of wild poliovirus from any stool
specimen.
2. An AFP case is classified as “non-polio AFP” if wild poliovirus is not isolated from
adequate stool specimens.
3. 60 day followup examination reveals persistent weakness or paralysis, or the child has
died or is lost to follow-up, the final classification of the case is one as “compatible”
4. All other cases are discarded as non-polio AFP

Role of pediatrician in adoption of child

Fundamental principles governing adoption
1. the child's best interests shall be of paramount consideration, while processing any adoption
placement;
2. preference shall be given to place the child in adoption with Indian citizens with due regard to the
principle of placement of the child in their own socio-cultural environment, as far as possible;
3. all applications for adoptions shall be registered on the Designated Portal and confidentiality of the
same shall be maintained by the Authority.
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Child eligible for adoption.

1. any orphan or abandoned or surrendered child, declared legally free for adoption by the Child
Welfare Committee;
2. a child of a relative defined under clause (52) of section 2;
3. child or children of spouse from earlier marriage, surrendered by the biological parents for adoption
by the step-parent.
Eligibility Criteria for Adopting a Child in India
The Central Adoption Resource Authority (CARA), the nodal agency under the Ministry of Women and
Child Care, oversees the eligibility criteria for adopting a child in India. The key conditions prospective
adoptive parents must meet include:
1. Citizenship: Adoption can be by an Indian citizen, Non-Resident Indian (NRI), or foreign citizen,
each with a different adoption procedure.
2. Marital Status: Any person, regardless of gender or marital status, is eligible to adopt.
3. Stability: Couples must have completed at least two years of stable marriage and jointly consent
to adoption.
4. Age Criteria: The age difference between the child and adoptive parents should be at least 25
years. Adoptive parents must be between 25 and 55 years old.
5. Health: Adoptive parents must be physically, mentally, and emotionally stable, with the financial
capability to provide for the child’s basic needs.
6. Single Parent Adoption: Single individuals, both male and female, can adopt a child.
Child Eligibility for Adoption
For a child to be eligible for adoption, the Central Government of India specifies that the child must be
orphaned, abandoned, or surrendered, declared legally free for adoption by the child welfare
committee. Specific criteria determine the eligibility of orphaned, abandoned, or surrendered children
for adoption.
The Adoption Process in India
The process for adopting a child in India involves several detailed steps:
Step 1 – Registration
Prospective adoptive parents must register with an authorized agency, such as a Recognised Indian
Placement Agencies (RIPA) or Special Adoption Agency (SPA). Registration involves paperwork,
formalities, and general preparation guided by a social worker.
Step 2 – Home Study and Counseling
A social worker conducts a home study at the prospective adoptive parents’ residence, exploring
their motivations, strengths, and weaknesses. Counseling sessions may be required to gain insights
into their readiness for adoption.
Step 3 – Referral of the Child
When a child becomes available for adoption, the agency notifies interested couples. Relevant
information, including medical reports, is shared, and the adoptive parents may spend time with the
child to ensure compatibility.
Step 4 – Acceptance of the Child
Upon comfort and agreement, adoptive parents sign documents indicating their acceptance of the
child.
Step 5 – Filing of Petition
All necessary documents are submitted to a lawyer, who prepares a petition for presentation to the
court. Adoptive parents visit the court, sign the petition, and file it.
Step 6 – Pre-Adoption Foster Care
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Parents take the child to a pre-adoption foster care center, understanding the child’s habits with the
help of nursing staff before taking the child home.
Step 7 – Court Hearing
Parents attend a court hearing where the judge may ask questions and specify the investment to be
made in the child’s name.
Step 8 – Court Order
Upon proof of the investment, the judge issues adoption orders.
Step 9 – Follow Up
The agency submits follow-up reports to the court regarding the child’s well-being, continuing for 1-2
years.
Role of Pediatrician
1. Counsel and teach the parents about the process of adoption in a supporting and understanding
attitude complete medical re-examination to reassure about the child’s health and developmental
status.
2. Anthropometry , immunization status
3. Investigations- CBC, chest x ray, LFT , RFT , urine and stool analysis
4. USG abdomen, ECHO,serology for HIV, HbSAg, thyroid screening,
5. Special tests for hemolytic anemia, IEM, chromosomal anomalies depending on history and
examination
6. Ensure that diseases with window period (HIV,Hepatitis B) are repeated at 3 and 6 months before
placement
7. Follow up ad post adoption counselling-
a. Nutritional status, immunization, growth and development.
Parents who wish to relinquish their children due to any reason should be counselled about the correct
procedure, so that children are not left in public places which may be unsafe and traumatizing.

SABLA programme (Rajiv Gandhi scheme for empowerment of adolescent girls)

Sabla Scheme is also known as the Rajiv Gandhi Scheme for developing adolescent girls. It is an important
government scheme that focuses on developing young girls between the ages of 11 to 18. The SABLA scheme
aims at empowering Adolescent Girls (AGsz). It is done through nutrition, health care, and life skills
education. The scheme is implemented through Anganwadi Centres (AWc), panchayat community buildings,
schools, etc.
Objectives of Scheme for Adolescent Girls
1. Empowering young girls to lead a more productive life
2. Focusing on overall well-being through targeting nutrition and non-nutrition needs
3. Promoting skill development to make adolescent girls self-reliant
4. Upgrading their existing skills and tieing up with the National Skill Development Programme
5. Using the potential of Anganwadis, schools, and panchayat buildings to reach every vulnerable girl
6. Promoting Adolescent Reproductive and Sexual Health (ARSH), counselling, child care practices
among girls
7. Bringing out of school girls into the education system
Eligibility for SABLA Scheme
Under the program, all Integrated Child Development Services projects will include adolescent girls
between 11 and 18 (specifically those not attending school). This coverage will be implemented in
200 selected districts across all states and Union Territories. The target group will be divided into two
age groups: 11-15 and 15-18.
Implementation of the SABLA Scheme
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1. The SABLA scheme is a centrally-sponsored scheme implemented by state governments/UTs. The

government will provide 100% financial assistance for all inputs other than nutrition provisions.
2. The government will share assistance to the states to 50% of the actual financial norms or the
expenditure incurred by the states, whichever is less.
3. The Ministry of Women & Child Development is responsible for the budgetary control and scheme
administration from the respective centre.
4. The ICDS infrastructure will be used for the implementation of the scheme. The Anganwadi Worker
(AWW) will survey and register all adolescent girls within the jurisdiction of that Anganwadi centre
and advise them to come to the Anganwadi centre. The District Probation Officer (DPO) will be
responsible for implementing the scheme at the field level within the district. The Child Development
Project Officers (CDPO) will be responsible for implementing the scheme within the ICDS Project area
along with the supervisors.
Features of the Scheme for Adolescent Girls
1. Providing nutritional supplements regularly in adequate quantity. Each adolescent girl will receive at
least 600 calories and 180 gms of protein per day, as well as the recommended daily intake of
micronutrients, at a cost of Rs 5 per day per beneficiary, for 300 days per year. Iron and Folic Acid
(IFA) supplementation
2. Giving life skills and counselling: The main objective of LSE is to provide adolescent girls with the
necessary skills and knowledge for accessing public services in Anganwadi centres. Vocational
Training using NSDP
3. Providing information on public services like Primary Healthcare Centres, Post Offices, Police Station,
and Banks
4. Improving the overall well-being by educating on hygiene and family welfare.