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RF_CH_7.2_SUDHA
IN
Medical
Officers’
Conference
COONOOR
2nd September 1979
UPASI COMPREHENSIVE LABOUR WELFARE SCHEME
Glenview
Coonoor-643 101
Nilgiris
At
Birth
:
Child weighs 2500-3C00 gms.
Length-50.8 eras, or 20 inches
Child in flexion attitude with all new born reflexes present
0-4
weeks
:
Flexed attitude, headlag + , Turns from side to side. Doll’s eye move
ment + ‘ Moro’s Stepping, placing and grasp reflexes active.
At
4
weeks
:
Lies with legs more extended. Turns head tonic neck posture predo
minates, headlag + when brought to sitting position, watches mother
able to follow objects for a few degrees.
At
8
weeks
:
Attitude general extension. Able to raise head slightly, tonic neck
posture predominates head lag still persistent. Follows moving object.
180°. Smiles on social contact. Cooing + and listens to voices.
At
12
weeks
:
Able to lift head. Head control partial. Reaches towards and misses
objects. Bobbing movement of head + , moro reflex-does not persist.
Sustained social contact and cooing 4-
At
16
weeks
:
Lifts head and chest, symmetrical posture predominates, hands in mid
line, grasps objects and brings them to mouth. No head lag. Able to
sit with trunk support. Able to focus on small objects makes a move
for them, laughs, agitated when social contact is broken. Excited at sight
of food.
At
28
weeks
:
Rolls over
May pivot. Lifts head, sits with pelvic support, bounces
actively when made to stand.
Reaches out and grasps larger objects.
Transfers from hand to hand.
Prefers the mother, babbles, responds
to changes in emotional content of social contact.
At
40
weeks
:
Sits up indefinitely. Back straight. Pulls up to standing position.
Crawls. Grasps object with thumb and forefinger. Picks up small
objects with assisted pincer movement Attempt to retreive dropped toys.
Starts saying mamma dadda, enjoys playing hide and seek. Waves bye
bye.
At
one
year
:
Walks when held with one hand or with support of furniture. Picks up
small objects with unassisted pincer movements and releases object to
another person on request- Able to say two to three more words other
than mamma or pappa. Able to play with toys and assists in dressing.
Weight — Weech's Mnemonic
At birth
:
7 lbs.
3-12 months
:
Age in months + 11 lbs.
1 -
6 years
:
(Age in years X 5 + 17)
6-12 years
:
(Age in years X 7 + 5)
After 3 years
It can also be calculated (Age + 3X5) upto 12 years of
age.
1
I
A YEAR FOR THE CHILD
"Ultimately, of course, it is the
human being that counts and if the
human being counts, well, he counts
much more as a child than as a
grown up."
- Jawaharlal Nehru
February 26, 1979.
Tl
All Members
Dear Sirs,
1979 is the International Year
of the Child (IYC).
The decision to
declare it as such was taken two years
back by the United Nations in the pious
hope that there will be a greater aware
ness of the needs of the large number of deprived
children, especially in the developing countries,
who live - and die - in poverty,malnutrition and
ill-health.
The need for a greater concern for children in
India is evident from the following statistical
information
•»
.. 250 millions or 400
Child population (below
14 years)
of the population
.. 140 of the children
Death before the first
birthday
born
.. 400 of the children
Death before the fifth
born
birthday
.. 4 lakhs per year
Death due to malnutrition
(below 5 years)
Handicapped children
.. 3 millions
Children in employment
. . 30 millions
Illiteracy among children
. . 600
(above 10 years)
Expenditure on'education
. 50 paise per day
per child.
.. 2
2
Although various programmes have been drawn up
by the Government for the IYC, they can, at best, touch
only the fringe, of.what is a massively Himalayan task.
Voluntary bodies have also joined in -the cause of child
ren but it could well be that the. IYC - like the
International Women's Year - turn out to be yet another
listless ritual.
We are, however, anxious that this
does not happen in the plantation, sector.
Apart from the statutory protection afforded to
the child population on plantations, the UPASI Comprehen
sive Labour Welfare Scheme has, as one of its objectives,
the CARE OF THE YOUNG and more than one-third of our
membership already has an on-going programme for children.
While efforts are under way to intensify efforts in this
direction, it is our hope that those who do not subscribe
to the CLWS will also be able to develop an action
programme for the welfare of children on their estates.
This could be on the following lines :- Estates having dispensary/group hospital
could have an extended Maternal & Child
Health and Family Welfare Programme .
This will enable the pregnant worker to
deliver a healthy child. Further, the
improved care will minimise the incidence
of disease among children. It should also be
possible to put all children under six years
on a "Road to Health" chart.
- .An Education Programme could be initiated so
that mothers are induced to take better care
of their children, particularly, in areas
of correcting faulty dietetic practices and
providing supplementary food to improve the
calory intake.
.. 3
- 3 -
Activating the Creche by «
” improving attendance
™ using it as a centre for health monitoring
- providing supplementary nutritional inputs
- imparting baste education and preparing
the children for achcw&l
- organising baby contests, games and group
activities for th® overall development of
the child
“ identifying handicapped children with a
view to rehabilitating them
- early detection of preventable morbidity
and organising eye camps.dental camps ®tce
These are only our minimal suggestions and they could
be acted upon straight away within the infrastructure already
available and w>any material cost increase.
In viewing the 1YC as both “a challenge and an
opportunity* let us not overlook the fact that a child
development progiamme on the estates also has a long-term
slgnlffcat'Ce. Most of the ch Idren of today will be our
workers of tomorrow and, as Mr,Maurice Pate, UNICEF' a
first Executive Director, observed s "Children are the
future s they are the seed for the hoped-for harvest of
the world - as precious and as rich in promise aa th®
carefully nurtured wheat grains of the knowing farmer."
yaurti faithfully,
SSCRglAR?
UNITED PLANTERS’ ASSOCIATION OF SOUTHERN INDIA
POST BOX NO ,1
OIBNVIBW
C00N00H
GH 9-U
CONDENSED FROM "NATIONAL PLANOF ACTION FOR INTERNATIONAL
YEAR OF THE CHILD 1979".
CHILD. HEALTH AND NUTRITION,
According to 1971 census, the child population of
India was 42/a of totel population, infant mortality rate
is as high as 122 per 1000 live births, suggesting that
lot of effort is still needed to promote child health.
Importance of first 6 year of age of child for its
growth and development is well known, there is no doubt
that malnutrition cither directly or indirectly is the
biggest single contributor to child morbidity and mortality
in our country; caloric-protein malnutrition has been
identified as the crucial problem amongst under sixes.
The prevailing Indian situation in relation to
Maternal a.nd Child Health (MCH) reflects r.n woeful inade
quacy of achievement and leaves out immense ground yet to
be covered.
The importance of health and nutrition in the
overall development of the child should be given greater
emphasis. The problem calls for formulating as strategy
with full broad goals:
1.
Reducing infant and child mortality and
morbidity;
2.
Reducing maternal mortality;
3.
Ensuring adequate maternal and child health
care ;
4.
5.
Preparing of boys, girls for wise parenthood;
Wider community cduca.tion/health and nutrition ./on
To realise these goal, a.number of specific action
programme as suggested below must be initiated, if in
existence enhanced in the International Year of the Child:
Immunisation:
Preventive programme to reduce morbidity should be
undertaken on a larger scale:
a) Every newborn child should be protected
against smallpox, TB, whooping cough,' Diptheria ,
Tetanus and polio by immunisation .
b)
Mass immunisation campaign should be.
organised to cover the most weakest and
vulnerable section of tho population.
2
2
Nutrition:
Measures for detection of early cases of malnutrition
must be intensified so as to prevent the cases from reaching
a stage of No return.
Domiciliary of malnourished children encourage
extended. All children below 6 years of age, especially
those below 3 years, of weaker sections should be provided
nutritional support in the form of inexpensive and nutri
tional supplementary foods produced locally.
Large scale distribution of Vitamin 'A1, Ferrous
Sulphate, Folic Acid should be undertaken to prevent
blindness and nutritional anemia among children, pregnant
and nursing mothers.
Community resources should be mobilised for raising
kitchen gardens, poultry units and dairy farms to improve
nutritional status of the community.
Nutritional education:
Mass educational programme should be launched to
create health and nutritional awareness.
Basic instruction
in nutrition education should be imparted through elementary
schools.
Simple health ".nd nutrition education materials,
attractive posters and guide books or manuals should be
prepared for teachers and health workers.
Family welfare planning is of crucial importance to
child welfare and as such, to be promoted energetically in
International Year of the Child.
School Health:
Health services for school children should be inte
gral part of school activities.
It should include supple
mentary nutrition, hee.lth check-up, referral services and
immunisati on.
Environmental Health:
Schools should have safe drinking water, sanitary
latrines, adequate light and air and clean surroundings.
Sale of unprotected eatables around the school premises
and residential areas must be banned and such bans
strictly enforced.
Supply of safe drinking water, periodic disinfection
of wells, environmental and personal hygiene should be
promoted.
In order to promote environmental sanitation,
the use of Bio-gas plants should be encouraged.
3
Do cunentation:
The present system of registration of vital events
is truly the ’Achilles He^l' of community health programmes
as assessment and evaluation of existing indices in a
given area is the foundation on which preventive and cura
tive services is provided.
The proper and complete documentation of all vital
events of an individual or family or a community in
relationship to the environments helps the doctor to provide
the necessary preventive and curative services to the
community.
Public health without statistics has been compared
to a ship without a compass.
Uses of health and vital
statistics are several:
of
1) To measure the state of health/a community
and identify its health problems,the natures,
their sizes and their distribution among the
various population groups so that, available
health and medical care used with make effect.
2)
For planning and administration of health
services.
3)
To estimate future needs of the community and
to fix suitable targets for achievements forevaluating the progress, success or failure of
health programme and services.
sspd.
23 .8,1979
CH
CHILD MENTAL HEALTH AND PSYCHOLOGICAL DEVELOPMENT.
At a time when we are still struggling to deal with
high death rates and high physical morbidity in children
a concern with psychological development and mental health
problems might be thought to .be a dispensable luxury.
This
is not the case.
In the 1st place different aspects of child's develop
ment should not be separated artifically, but, integrated
into a holistic approach.
Improvements in physical health
will also aid p^ycholosocial functioning.
Thus relief of
malnutrition would aleviate the apathy and misery that so
often accompanies serious malnurishment.
In the 2nd place, mental health problems deserve
attention in their own right.
Judged by the criteria of
frequency, seriousness, socio-economic consequences, and
community concerns, they merit an important place in Health
service planning.
Thirdly, unless steps are taken to prevent it from
happening, the socio-economic changes taking place in
developing countries are likely to bring an increase in the
psychosocial problems.
Increasing prosperity will not
necessarily aid psychosocial development. Action is needed
now or its may be too late.
The WHO expert Committee on child mental health and
psychosocial development concluded that - a vast amount of
knowledge at present remains unused, and that its applica
tion might substantially improve the fate of children.
Action should be directed to the promotion of mental deve
lopment and health in children because this would lead to
overall developments.
Such action would not require vast
resources but, mainly the reorientation and co-ordination
of activities undertaken by various sectors of community
services and by the community as a whole.
Prevalence and need for action:
Persistent and socially handicapping mental disorders
affect between 5 and 15?° of all children aged 3-15 years.
Par from being a luxu-ry in developing countries, concern
with childhood mental disorders is .especially appropriate
in these areas where children under 1 5 years account for
about 40% of the population.
Poverty and especially low
socio-economic status appear to be associated with a
greater incidence of mental disorders.
The physical ill
effects of poverty such as malnutrition and complications
of pregnancy and child birth can themselves lead to
increased mental and emotional disorders in children.
Conversely the welfare of a country depends on the produc
tivity of its people. Even mild and transient mental
disorders in children can do irrepairable harm to society.
2
2
For example, a child with emotional disorder may drop out
of school and become educationally handicapped.
In addition
to being nonproductive mentally handicapped adults may
perform so poorly as parents that the next generation is
born into severe deprivation.
Mental health problems prevalent in children may be
considered under 3 main groups:
1)
Emotional disorders (e.g., fears, anxiety,
depression, obsessions, hypochondriasis)
occur with the same frequency in boys and
girls.
2)
Conduct disorders (poor peer relationship
and distructiveness constitute the main
features) are significantly more common
in boys.
Particularly in younger children
a sub-group can be identified in which over
activity .correlates with a serious lack of
attention paid to the child.
3)
Impairments or delays in development are
markedly more common in boys than in girls.
Developmental disorders of speech and
language occur in some T —5% of children.
Regular bedwetting is present in about 3%
of children at the age of 10. Reading
retardation in children of normal intelli
gence is found to be present in about
3-10% of children.
Other groups of disorders including epilepsy, organic
brain syndromes, sensory impairements, communicable diseases
and systemic physical disorders. Not only are they important
problems in their own right but they may also occur in
association with other mental health problems in children and
aggravate their course and consequences.
Course of mental disorders in children:
In so far as most mental disorders in childhood
constitute variations from normal psychosocial development
rather than disease entities it might be thought that they
are of little concern and need not draw on limited service
resources.
However, this would be a seriously mistaken
view. Not only are such disorders a source of considerable
suffering to the child but they are also associated with
serious social problems and may be forerunners of serious
psychiatric and social difficulties in adult life.
The great majority of children with specific delays
in speech or language, talk normally by middle or later
childhood. However, many of these children go on to have
serious difficulties in reading and spelling.
In some
3
3
cases, these are associated with emotional or conduct
disorders.
Although most individuals with mild mental
retardation have scholastic difficulties in childhood,
the great majority hold regular jobs in adulthood and
rear ordinary families. On the other hand although they
can be taught many useful skills, severely retarded
individuals usually remain dependant, and very few of
them become gainfully employed or produce offspring.
Short-term followup studies of children who have suffered
nonaccidental injury suggest that a high proportion have
learning and behaviour problems at school. The same is
probably true of less severe disturbances of early parent
child relationship.
Individuals who suffer rejection and discord during
their childhood are more likely when adult to have both
marital problems and difficulties in bringing up their
own children.
A background of seriously abnormal upbringing
is often seen in the case of parents who deliberately injure
or grossly neglect their offspring.
The two other groups
in whom intergenerational continuities are most evident are
individuals with conduct and personality disorders and those
with mild mental retardation.
In both cases there is a
higher risk of similar disorders in their children than is
the case in the general population.
Factors influencing psychosocial development;1.
Biological factors:
Individual differences between children are observed
from birth onwards and these differences influence psycho so ciaj.
development.
Whereas very few mental disorders in childhood
are • inherited as such, genetic factors do play a role through
their influence on personality and on vulnerability to envir
onmental stress.
In all societies in which it has been studied, brain
damage or dysfunction (such as indicated by cerebral palsy
or epilepsy) has been found greatly to increase the risk of
mental health problems.
There is good evidence that brain
dysfunction is important in its own right as a cause of
mental illness, quite apart from the effects of psychosocial
stress or disadvantage with which it may be associated and
the intellectual impairment or specific cognitive deficits
that may follow it.
In addition* it is well known that the
great majority of cases of severe mental retardation are a
consequence of brain disease or damage. Organic brain
dysfunction also plays a part in the genesis or some cases
of mild mental retardation, but psychosocial influences are
in this instance usually more important.
4
4
2.
Cognitive factors;
In all literate societies in which the matter has been
investigated, emotional and conduct problems have been found
to be relatively; common in both mentally retarded children
and children with specific disorders of 'learning or language
development.
It is probable that several different causal
precesses are involved in these associations. Firstly, the
mental disorders may stem’ from the same-basic factors that
led to the cognitive impairment i.e., the brain da.mage or
the psychosocial deprivation.
Secondly, the risk of poor
mental health may stem in part from the experience of school
failure. This is suggested both by the pattern of correlations
and also by the a.ssociatipn between cognitive impairment and
mental disorder, which tends to be more marked in relation to
children's behaviour at school than at home.
In so far as
the second mechanism is valid, it implies that the risk of
poor mental health need not be inevitable. Alterations in
the school environment to aid both the acceptance and
functioning of the low-achieving child might being benefits.
3.
’ Ecological and social factors;
It has been found in developed countries that mental
health problems in children are more common among those living
in inner cities than among those in towns or rural areas. It
appears that this is due in large part to the higher rates
of family difficulties in inner city areas.
Children's
psychosocial functioning can be more frequently impaired in
the cities because more children live in discordant unhappy
homes or have depressed or deviant parents.- However,
relatively little is known about the specific features of
city life that have this adverse effect on family functioning.
It is not urbanization per se because many medium-sized
towns have rates of disorder compare.ble to those in rural
areas; nor is it a function of population density or of
industrialization, because industrial areas may have relati
vely low rates of psychosocial disorder.
Migration is not necessarily associated with any
increase in mental health problems, and population movement
may sometimes involve psychosocial benefits.
Nevertheless,
in many countries migrants are at a disadvantage and there
are mental health risks associated .with major psychosocial
change.
The variables involved have not been well studied
but it seems likely that the risks stem in part from the
break-up of families and tribal or other community support
systems, the lack of adequate.child-care facilities which
follows from this break-up, the alienation of migrants in
the community or discrimination against them, and the very
poor living conditions in the slums-and shanty towns in
which many migrants have to live.
5
5
4.
Patterns of upbringing;
It has been well demonstrated in studies in both
developing and developed nations that variations in the
psychosocial development of children are strongly associated
with qualities of parent-child interaction. In particular,
it is known that when children are reared in homes where
there is a lack of conversational interchange, where parents
do not interact positively with their children, and where
there is a lack of play opportunities, the development of
language, intelligence, and scholastic skills is likely to
be impaired.
Similar associations have been found in
children reared in institutions and it may be concluded that
it is a causal connection.
This pattern of inadequate parent
child interaction is sometimes discussed in terms of "lack
of stimulation". Whereas it is true that children need
stimulation, both experimental and clinical studies show
that it is active experiences and interchange that matter.
Parents need to be helped to understand that it is not enough
to do things to their children; they must do things with them.
Verbal stimulation is provided by talking with the child and
not by turning up the volume of the radio.
Similarly, it is
helpful to provide toys, but children may also need to be
encouraged to create their own play opportunities.
There is
good evidence from numerous studies in a variety of societies
that there is a very substantially increased rate of mental
health problems in children who are unwanted or who experience
rejection, hostility, or serious family discord.
At one time it was thought that even temporary separation
of a child from his parents created a serious psychosocial
hazard. It is now clear that these arguments were to some
extent mistaken.
Children do need continuous relationships
with a small number of parent figures but brief separations
need not necessarily disrupt these relationships.
Good
quality day-care and a working mother are both compatible
with secure parent-child relationships.
Studies in maty different countries on parental deviance
have shown that children brought up by criminal or mentally
disordered parents show an increased rate of mental health
problems.
While genetic factors may play some part in this
association, it is clear that the hazards are in considerable
part a function of the family discord and disturbed patterns
of child-rearing that often accompany parental mental disorder. •
In the past, great attention has been paid to certain
patterns of child care such as timing of weaning and toilet
training, methods of discipline, and the like.
It is now
clear that these concerns were misplaced.
Within quite
broad limits the timing and mechanics of these aspects of
child care are of little psychosocial concern.
On the other
hand, the quality of care (in terms of sensitivity and
responsiveness to the child's needs), the relationship bet
ween the child and those who look after him, and the consistency
6
6
O'f
and efficiency of.child-rearing methods are/gome importance.
Markedly inconsistent patterns of punishment, repressive or
brutal handling, and a lack of concern all increase the risk
of mental health problems.
It has already been noted that day-care for young
children need not interfere with harmonious and secure
parent-child relationships.
It should be added that good
quality day-care can hove positive psychosocial benefits,
particularly in the case of children from poor or disordered
homes.
Obviously much is likely to depend on the quality
of care provided, but so far there is no good evidence to
suggest that either day-caife or preschool education has such
P- lasting benefit to children’s mental health that it could
be advocated on these grounds alone.
5.
Ameliorating influences and factors leading to
POSITIVE development:
The possible protective factors include the following:
1)
Sex.
For reasons that are ill understood (but
which are proba.bly both biologica.1 and social), girls
appear less susceptible to most psychosocial stresses in
childhood.
2) Temperament.
Children with an adaptable temperament
are generally more resilient in the face of deprivation and
disadvantage.
j) Isolated nature of the stress.
It appears that
surprisingly little damage is done by even chronic stresses
provided they occur in isolation ( e . g . , parental mental
disorder in harmonious homes without social disadvantage).
However, multiple stresses interact to potentiate the psycho
social damage.
4) Coping skills. One study found that children who
were used to brief happy separation experiences (such as
staying with friends or relatives) coped better with the
stress of hospital admission.
Presumably, children can
acquire coping skills relevant to other stresses.
5) A good relationship with one parent.
It has been
shown that the risks to mental health that stem from an
upbringing in a discordant, unhappy home are appreciably
reduced if the child is able to maintain a good relationship
with one parent. -It is possible although not yet demonstrated
that good relationships with other relatives in/extended
family might have a similar beneficial effect.
6) Success or good experiences outside the home.
It
seems that good schooling can do something to mitigate the
effects of a poor home environment.
7
7
7)
Improved family circumstances.
When a child is
reared in a disturbed, quarrelsome family there is a sub
stantial risk to mental health. However, if family circum
stances improve and the later years of childhood are spent
in harmony, the risk is appreciably reduced.
These findings clearly indicate that there is much
potential for preventing mental health problems and that a
major improvement in children's psychosocial development is
possible through actions that are feasible in most countries.
Some widely held beliefs about what can harm children
' are not supported by facts:
1) Antenatal disorders tend to be more common
in inner city areas. However, it does not seem to be
urbanization per se that interferes with children's
psychosocial functioning, because many mediumsize towns
have rates of disorder as low as those of rural areas.
2)
Children arc not inevitably damaged by receiving
day care outside the home or by having mothers who go' out to
work, as was mistakenly ar^gued by some previous WHO expert
groups.
It has been demonstrated that good quality day
care can have positive psychosocial benefit's especially for
children from seriously disadvantaged or disordered homes.
. 3) Mental problems and abnormalities are persist across
generation lines, but discontinuity is nevertheless.more
frequent than continuity. For example, about 5 out of 6
children reared by mentally retarded parents are of normal .
intelligence. .And most individuals from unhappy discordants'
homes later go on to make stable marriages. Mental disorder
is not a function of population density, although it does
seem to be associated with serious Overcrowding in dwellings.
Preventive measures-:1 -
,
<
.General health measures:
There is good evidence that children with any form
»•
of organic brain dysfunction ( e.g., epilepsy, cerebral palsy,
or encephalitis) or with mental retardation have a much
increased rate of psychosocial and mental health problems.
Accordingly, any measures that substantially reduce the rate
of these conditions should also have mental health benefits.
There is good evidence that children with chronic physical
handicaps (of a kind that do not involve brain'damage) also
have a somewhat increased rate of mental health problems,
although the increase is less than is the case with brain
disorders.
Thus, any improvements in the general physical
health and wellbeing of children should also lead to gains
in psychosocial functioning.
a) Improved maternal and obstetric .care.
This is
important because perinatal complications may lead to cerebral
8
8
palsy and other forms of brain pathology, which in turn
predispose to mental health problems.
b) Improved nutrition. Prolonged malnutrition in
early childhood remains, an important main or contributing
cause of death in developing countries.
In those who survive,
it not only impedes physical growth but can impair mental
development, especially if coupled with a poor psychosocial
environment.
In this connexion the encouragement of breast
feeding and concern with the psychosocial aspects of physical
care are important factors.
c) Effective immunisation programmes.
In many parts
of the world poliomyelitis, tuberculous meningitis, and
tetanus (and to an. important extent measles, rubella, and
pertussis) remain bothlkillers and causes of chronic mental
and physical handicaps.
Immunization greatly reduces both
mortality and morbidity.
d) Reduction of accidents. Accidents are a principal
cause of death in children.
Survivors are often left with
brain damage from head injuries.
Steps to reduce accidents
such as the imposition of speed limits on roads, road-sense
training, and the provision of adequate play space for
children are therefore important.
e) Improved physical and social conditions.
The
control of most infectious disease depends at least ,as much
on better living conditions and pure water supplies as it
does jon improved medical treatment.
1
f) . . Better care of the chronically handicapped.
Many
.of the adverse psychosocial sequelae to chronic physical
handicaps are indirect consequences of the social restrictions,
educational difficulties, inappropriate medical treatments,
and stigmas associated with crippling conditions. Better
suppo’rt of families and improved medical, social, and educational care of chronically handicapped children would aid
their psychosocial development and reduce mental health
problems.
Social Welfare Measures
1.
The extensive evidence showing associations between a
wide variety of psychosocial- stresses or disadvantages and
mental health problems has already been mentioned.
There
is good reason to suppose that many of these associations
reflect causal influences; hence measures to reduce these
stresses or to foster development would improve children’s
psychosocial functioning.
9
9
2.
The av-'ide.nce of unstable - nd discontinuous patterns
of parenting:
Studies have indicated that children who repeatedly go
in and out of children's homes or foster homes, or who fre
quently change from one home to another, or who live with
their own parents in a severely unstable and unsettled family
environment have a high rate of difficulties in their psycho
social development.
There is also evidence that children
from stressful, discordant homes are more likely to develop
normally if they are adopted than if they remain in a
disturbed family environment. Accordingly, it is suggested
that, in the case of young children whose parents seem
unlikely to bo able to look after them, an early decision
should be taken with respect to adoption or long-term fostering.
3.
Improved conditions in day-care facilities :
It has been shown that children's development is
influenced by their experiences in day-care centres or
nursery schools.
It is important that there be continuity
in the staff who take care of the children so that each
child has only a limited number of people who. look after him.
However, them should be sufficient staff to provide them with
play,-talk and activities, and the centre should provide an
adequate range of experiences and learning opportunities. ' An
interaction between the day-care centre and the parents will
help to increase parental skills and confidence. ■' 1 •
4.
Improv-' 3. conditions in hor itals and other residential
institutions, together with a reduction in admissions:
Children's behaviour and development varies systemati
cally according to the social and psychological conditions
in the institutions in which they live for either short or
long periods of time.' There is some evidence that a change
in institutional conditions (as shown by hospital studies)
leads to changes in children's mental health functioning.
Parents should be strongly encouraged to visit children daily
in hospital and be able to do so without restrictions; in
the case of very young children it should also be possible
for a parent to be admitted with the child.
It has been found that repeated hospital admission
are associated with an increased risk of psychosocial and
mental health problems in later childhood.
The risk is
probably much greater among children already experiencing
psychosocial stress or disadvantage.
The implication is that
every effort should be made to treat ill children as out
patients or day-patients unless there are strong reasons for
admitting them to hospital. Emphasis must therefore be placed
on the development of community and outpatient facilities.
10
10
5•
Reduction in the number of unwanted births:
Children whose conception is unwanted, by their parents
may subsequently become loved, but this is less likely to
occur than in the case of children whose births were desired
from the beginning.
Children who are rejected are more
likely than other children to have mental health problems.
Clearly, it is no straightforward matter to take action to
reduce the number of unwanted births. The free availability
of family planning services is one important step but it is
not enough.
The individuals most likely to produce unwanted
children (young single people and people with many personal
and social problems) are just those least likely to avail
themselves of services. Usually it is not that they wish
to conceive a child or that they have ethical objections to
contraception but rather’ that their difficulty in planning a
family is merely one facet of a general problem in planning
all aspects of their lives. Accordingly, family planning
' must form part of a wider community service that is educational
in the broadest sense.
6.
Enhanced public awareness of children's needs:
It is essential that high priority be given to the
health and welfare of children and thus to the task of rearing
children.
Children learn through play, conversation, and
experiences, on all of which emotional and intellectual growth
. depends.
Parents need to appreciate' the distress often
experienced by very young children when away from home and to
recognise that their clinging on return is a normal response.
Sensitivity to,differences in individual children's needs
is important at, all ages, as is the requirement for the right
balance of emotional support and social control.
It is also
important for parents to realise that children are influenced
by the emotional climate in the home ,
These are but a few of
the general principles that people should know about children's
needs so that they will be better able to respond appropriately
as parents, as teachers, or indeed as anyone who comes into
contact with young people.
sspd.
29 .8.1979.
ch
MORBIDITY AND MORTALITY AMONG THE 0-6 YEAR OLDS.
. By
Dr.(Mrs.) Sulochana Unnikrishnan,
UPASI.
********
INTRODUCTION;
The plantation community may be divided, into 3 broad
categories - the workers, the medical personnel and the
management.
It was felt that a study into the patterns of
morbidity and mortality among the vulnerable 0-6 population
here would, apart from being appropriate in 1979, be of
value to all three sections mentioned above - the working
mether whose suffering is both mental and financial, the
doctor, one-fourth of his outpatients being made up of
worried mothers and wailing children and the manager,
concerned about his mounting absenteeism figures. Viewed
from a larger perspective, there is no exaggerating the
importance of such a study as we are talking about our
human resources whose health has a bearing on the economic
and social growth of the country.
Plantations due to their
isolated situation and closed nature of the community would
perhaps be the best suited for a study of this. type. Hardly
any deaths go unreported here; when someone is ill and
convinced of the need of medical care he invariably has to
go to the estate hospital.
The very same reasons make
plantations ideal for a 'total health care’ approach.
METHODOLOGY ;
Statistics from 4 estates were collected for this .
purpose. These are estates where an intensified total
health care delivery system'is being adopted for more than
a year now.
The reasons’for giving them special attention
were their high mortality and birth rates as well as increased
incidence . of water-borne....illnesses when compared to ’other
estates in the area.
The 0-6 population'of these 4 estates
_. _w_as. .1389 in 1978 making up 18.55%> of a population of 7489.
1976 was taken as the base year for this paper.
Statistics
for 1978 were collected for comparision.
The objective of
this effort may said to be two fold;-
■’ 1’) 'To study the pattern of morbidity and
mortality in the 0-6 year olds.
2)
To find out the imjpact, if any, of the . .
total health care approach on the
incidence of illnesses and deaths
among these children.
■
2
2
Morbidity figures were taken out agewise from the
out-patient registers of the respective hospitals.
The
diagnoses and age entered therein by the peripheral medical
staff was accepted.
When the complaints were charted out
they were found to fall into the major categories of
respiratory tract infections, common water-borne illnesses
and fevers including influenza. Upper and Lower respiratory
infections, bronchitis, bronchopneumonia, cold and cough were
put down under respiratory tract infections.
In water-borne
illnesses, diarrhoea, dysentry and gastro-enteritis were
included.
One single case each of Typhoid and Hepatitis has
been recorded which was left out from this category.
The
diagnoses given as Pyrexia of Unknown Origin, influenza and
fever come under fevers.
Mortality and still-births statistics are from death
and still-birth reports.
Population figures for 1 976 are from a survey conducted
by UPASI early that year.
Those for 1978 are from estate
office records except the 0-6 population which is from an
actual enumeration of the CARE feeding beneficiaries.
The outpatient figures for 3 months were further
analysed in detail to study the pattern of repetition in
these cases.
It was felt that it would be extremely
difficult to do such-a study for the full year and so this
was done for the months of March, April and May for diarrhoeas
because previous statistics have shown their incidence to be
maximum during this period.
Similarly for respiratory com
plaints, May, June and July figures were taken.
OBSERVATIONS:
Out-pati ent s:
Population and morbidity.
(Table 1 . ) .. ... ~
Morbidity
Popiilati on
Year.
Total
No. of
out0-6 year
pati ents
olds .
(New cases)
Total
0-6 yr. °/o of 0-6
olds .
yr.olds.
1976
8369
1 469
17-55
26383
3443
13.05
1 978
7489
1389
18.55
27609
3227
1 1 .69
% of 0-6
yr. olds
in the
O.P.
The total population as well as the number of 0-6
year olds seem to have decreased in these two years .
3
3
• The total number of new cases treated ha.s gbne up in
1978, from 26583 to 27609 in spite of which the 0-6 year
olds treated has fallen from 3443 to 3227.
Frequency of attending outpatients among
0-6 year olds for a period of 3 months
1976 and 1978.
1 976
IIo . of times
(JP attended.
1978 .
Number of
No . of times
children.
OP attended.
COMPIAINT.
Number of
children.
Diarrhoea '
&
Gastroenteriti s.
181
13
Nil
2
1
2
3
4
135
13
6
—
1
2
3
4
Respiratory
tra ct
infections.
214
16
4
2
1
2
3
4
198
23
6
1
1
2
3
4
The 1976 figures show that out of 196 cases who came
for diarrhoeas, 13 had come twice and 2 had come 4 'times
for the same complaint within a period of 3 months.
The
total for 1978 has come down from 1 96 to 154 out of which
13 children came twice, and 6 children 3 times.' A. similar
pattern is seen in the case of respiratory tract infections
also.
.
.
Table 3*shows that respiratory tract infections,
.water-borne illnesses and fevers in that order were the
major complaints that brought the 0-6 year -olds to the
hospitals. This was more so in the younger age group.
These illnesses covered 88.84?° and 67.09J& of the morbidity
in 1976 and 1978 respectively.
Sex did not seem to make
any significant difference in the morbidity rates. (* see
Annexure)
Figure A gives the major illnesses as percentage
of the total outpatients for each age group. It is seen
that in 1978, respiratory tract infections were maximum in
the infants and the incidence decreased as the children
grew„older. Water-borne illnesses are more in the 1-2 year
olds and incidence -of fevers seems to increase with age.
In general the same trend was observed in 1976 also. .
A comparision of incidence of the 3 major illnesses
in 1976 and 1 978- is shown in figure B. Reduction is
observed in all coses, the most significant fall from
789 cases to 480 cases have been observed in the incidence
of waterborne illnesses in the 1-6 year olds. Fevers did
not show any set pattern.
4
4
Table 4 in the annexure gives the breakdown of table
3 as to the actual number of cases in the different categories.
This shows that water-borne illnesses in the age group under
study have shown the maximum reduction, from 1058 to 711.
Respiratory tract infections have fallen from 1224 to 1086
and fevers from 585 to 513.
Inpatients:
'
Inpatient figures for both the years could be obtained
for two estates only.
Details are given in table 5.
Total
0-6 year inpatients for 1976 was 128 and for 1978 it was 95.
They formed 18.34 and 14.03 of the total inpatients for these
years. Here too the major categories remained respiratory
tract infections, diarrhoeas and fevers - 31 .58% and 8.52%
and 13.68% .of the .total 0-6 year admissions in 1978. (Table
5 annexure). Admissions for measles is observed to have gone
up from 4 in 1976 to 38 in 1978 (Table 5 .annexure).
Figure C shows that admissions for respiratory tract
infections were lower in 1978 than in 1976. - 46 and 30
respectively; similarly the number of cases admitted for
diarrhoeas has come down from 20 to 8 and fevers from 32
to 13.
Table 5 also shown that there were no admissions for
dysentry in 1 978 as against 7 in' 1976. . So too there have
been no cases of malnutrition, Kwashiorkor or deficiencies,
which category had 4 inpatients in 1976.
MORTALITY;
There were a total of 49 deaths in the age group under
study in 197^5 this figure has come down to 23 in 1978.
(Table 8 in annexure and Figure D.)
Deaths in the first one' week of life remained the same,
6, in both the years.
Neonatal mortality after the 1st week
seems to. have come down from 9 to 5. Maximum reduction is
observed after 1 year of age - from 29 in 1976 to 7 in 1978.
The number of still births were 11 in 1976 and 8 in.
1978 (Table 8 annexure).
Thus the number of perinatal deaths
was 17 in 1976 and 14 in 1978.
0-6 year deaths/medical attention
re ce ived.
(Table 9.)
----------
ToFemale.
OP/li-5
Inpatients .
'
deatnes.i hs.
■1 2
10
12
2
49
23
ii
u
il
n
il
il
n
II
il
1
1
v io
16
8
il
1976
1 978
n
Year.
I
Male .
OP/lines•
Inpatients.
5
5
Table 9 shows that majority of deaths took place in
the hospitals in 1978, 18 out of 23* No significant
difference is observed in the matter of hospitalisation as
between the sexes. Mortality i@ almost equal in males and
females - 25 and 24 in 1976 and 11 and 12 in 1978.
Prematurity and bronchopneumonia remained the major
^TTlers in the 0—6 yecr olds and does not show any reduction.
There were 9 cases of prematurity for both years; 10 of
bronchopneumonia in 1976 and 9 in 1978.
There have been no
deaths due to gastro enteritis, malnutrition, measles, enteric
fever and neonatal.infection or septicaemia in 1978 as against
20 deaths due to the above causes in 1976 (Table 8.)
DISCUSSION; '
While collecting statistics for this paper the 'need
for a standardised documentation system was keenly felt.
With the present system of record keeping a great amount of
time and effort are needed in extracting the relevant
information.
The value of such information in planning,•
accomplishing and evaluating one's health care delivery
methods, justifies the extra effort put in on documentation.
It would be relevant at this juncture to summarise
the extra inputs covered by the term total health care, made
on these estates.
These were :-
1 ..
Health education through link workers and health
talks.
2.
Supplementary CARE feeding programme in the creches.
3.
Each child being put on a road to health car1?' and'
regular monitoring of his/her weight.
4.
Almost 100% coverage of these children with pro-phylactic Vitamin 'A' .
5.
Supply of ferrous and folic acid tablets to
selected children and all maternity cases.
6.
Attention to water supplies and fly control
measures.
7.
A more purposeful MCH programme including
immuni sation.
8.
Lost but perhaps the most important, very good
co-operation in the matter of all these between
the management and the medical' department.
The total population as well as that of the 0-6 year
olds seem to have reduced in these 2 years. It may be
argued that one cannot go by the total population figures
which can fluctuate with the retirals and recruitment of
labour. Yet a decrease in the 0-6 year olds may be of
importance in view of the fall in the birth rate from 44.65
in 1976 to 39.30 in 1978.
The birth rate on these estates
6
6
is still very much above the district average which is only
30.75/1000 population.
(
The percentage of 0-6 year olds in the out-patient
has decreased which may.be attributed to better health in
• thi s age- group .
"•
Respiratory tract infections, diarrhoeas and fevers
make up about two-third of the illnesses in the age group,
under study.
Incidence of all three categories has decreased,'
the most -significant reduction having been observed in diarr
hoeas. One of the reasons may be the fact that out of a
total of 11 divisions on these estates 6 divisions have
chlorinated water supply now.
The total outpatients for
water-borne illnesses on these estates came down from 3727
in 1976 to 2845 in 1978.
Apart from this the educational
efforts have resulted in improved hygiene and sanitation and
an awareness in this regard among the workers.
The maximum
reduction is observed in the 2-6 year olds who incidentally
must be the category who benefit most from the supplementary
feeding programmes.
Respiratory tract infections charted agewise show•a
clear downward curve in both years.
When the outpatient
figures were taken out it was seen that there were hardly
any cases in the 0-1 month group and so these were included
in the 0-1 age group.
The highest incidence was in the 1
month to 1 year group in the case of outpatients as well
as inpatients.
This was so far both 1976 a.nd 1978.
The
possible reason may the low ns•ural resistance in these
infants.
There is a reduction in respiratory tract infectionstions also from 1976 to 1978 both in the outpatients and
the inpatientsAnother finding is that more cases of
measles were admitted in 1978 but there were.no deaths due to
measles.
In 1976, 4 deaths in the 0-6 age group have been
recorded as due to measles with bronchopneumonia.
Perhaps
prophylactic Vitamin 'A1 and increased resistance due to
supplementary feeding have contributed to the reduction in
respiratory tract infections.
One class for the link
workers covered measles and its management; perhaps this
has contributed to the increased admissions of measles cases
to the hospital.
MORTALITY;
The number of deaths when charted agewise showed a
downward trend in 1978. In 1976 there seemed to be more
deaths in the 8 days to. 1 month group than in the 1st week
of life; the number of deaths in the 1st week of life has
remained the same in both years.
The reduction in perinatal
mortality is due to the decrease in still births and so
cannot be taken as significant. Prematurity and bronchop
neumonia remained the major killers in both years.' No
reduction in this has been achieved.
In the district,
7
7
prematurity accounted for 52.59% and bronchopneumonia for
24-14% of the 1978 infant dee,ths.
The comparable figures
for these 4 estates are 56.25 and 31.25 respectively.
Prematurity may be due to anaemia in the pregnant
women, sexually transmitted diseases or lack of nutritional
food during the last trimester of pregnancy. In view of
these possibilities routine VDRL test is done for all
antenatal cases these days. However, the figures point to
the need for better and more purposeful antenatal and post
natal care, promotion of hospital deliveries and education
of mothers.
Incidence of bronchopneumonia may be aggra
vated by climatic conditions, state of repair of creches
and lines, lactacting mothers working in the fields during
monsoon coming in their wet cumblies and clothes and feeding
the babies etc.
The chill a child may catch sitting and
playing on the damp cement floor of the creches was behind
our minds when ’attalais' or wooden platforms were provided
in the creches for the children to sit and play and sleep.
From 1976 to 1978 there has been a good fall in the
8 days to 1 month mortalities.
A noticeable- reduction is
observed in deaths after 1 year.
This fact is reflected in
the inpatient figures also where apart from the peak
produced in the 2-3 age group due to the measles admissions,
the total number of deaths have recorded a reduction in all
age groups from 1 to 6.
More significant is the fact that
there were no deaths- due to malnutrition, neonatal infections
gastroenteritis and measles. ■ In general this shows better
resistance and better health in the 0-6 year olds towards
which the supplementary feeding, Vitamin 'A1, health
education, improved sanitation and waste disposal' all could
have contributed. No particular difference was noticed as
between the sexes in the matter of hospitalisation when ill.
A study of the mortality in the two sexes did not reveal
anything significant.
CONCLUSION;
A study was made into the mortality and morbidity
patterns of the 0-6 year olds on 4 estates. Morbidity and
mortality cannot and should not be viewed as isolated
entities divorced from their back ground and setting. In a
developing country like ours nutrition, education, housing,
hygienic disposal of waste, water supplies, all spell health,
in different ways.
This is the rock on which the more
affluent nations have built their medical edifice. It would
be folly to envisage vertical growth without a solid base.
This country of ours with its myriad problems cannot afford
to have its educated intelligent minority wearing blinkers.
In an industry illhealth also means, substandard work,
absenteeism, and mandays lost.
So when we say that in 1978,
3227 0-6 year olds came to the outpatients it also means
atleast double that number of working hours lost, mothers who
did not get ration money for the week, whose earnings were
reduced and lowered productivity.
8
8
There are two ways of dealing with morbidity and
mortality rates.
One is by stocking the hospita.l with more
and more drugs and waiting for the patient, to come to you.
This'will dicharge our duty to the individual patient, but
does not deal with the other problems attendant upon a sick
child in the outpatients in an industrial setting. The other
and more reasonable way would be to fight the battle against
illnesses, making use of all available weapons in our armoury
in other words, the total health care approach.
This latter
has been basically accepted by the plantations as a philosophy
and it is to this end that the management, medical department
and the UPASI are striving.
Such a system of total health
care includes a more purposeful ante-natal a.nd post-natal
programme with set targets and evaluation, educational efforts
through link workers and health talks, regular monitoring of
health of the children through under-five clinics and weight
cards, the creche development programme, attention to water
supplies etc. Here a streamlined system of documentation goes
a long way in identification of priority areas,- early inter
ventions and improving the quality of services in general.
We find that the morbidity on these 4 estates have
decreased from 1976 to 1978; mortality has halved from 49
to 23.
Comparable figures for other estates, other states
or all India were not available. Yet, higher mortality in
the neighbourhood is no consolation nor should it make us
complacent.
The planning and efforts, required to eliminate
the last preventable death, within the existing constraints
and resources are worthy of the highest intellect, the
noblest heart.
.
ACKNOWLEDGEMENT;
T.
Thanks to Dr.(Mrs.)V. Rahamathullah for her-.
guidelines and help in preparing the paper.
2.
.Thanks to. the estates managers for the co-operation.
3.
Thanks to the estates medical officers and para
medice 1 staff, who helped in compiling data.
4.
Thanks to the Chief Medical Officer for his help.
Ends : a/s .
sspd .
30.8.1979.
High Risk Infants,
These are babies with low birth weight, babies born
after difficult labour, twins, babies with jaundice and
babies with -other neonatal complications.
These high
risk babies contribute largely to the perinatal, neonatal
and infant mortality rates.
Low birth weight;
< ■
By International agreement any baby weighing less than
2,500 grams at birth is called a low birth weight baby. If
the birth weight is not specified a live born infant with a
period of gestation of less than 37 weeks is considered as
equivalent of an immature infant*
As it is difficult-to
know how immature a baby is WHO (1961) recommended, that the
concept of prematurity-be replaced by.that of low birth
weight for all infants weighing less than 2,500 grams.
Import ance ;
-
A low birth weight baby is a ’Paediatric priority’
.
because the baby has less chances of survival than babies
weighing pyer 2,500 grams.
Half of all perinatal and_.'.h.._,<_.^.‘.^
l/3rd of all infants deaths are due to low birth weight.
Further prematurity contributes to mental and physical •'
handicaps especially in those who have-not received expert
neonatal care.
Causes;
The most important causes as far. as India is concerned
are maternal malnutrition and anaemia. . . .
.
.
Other cnuaea-are,
1.
>
Maternal — Syphiilis,-heart disease, toxaemias of'
'•* ^pregnancy, diabetis,-accidental injury,
uterine malformations, ovarian tumors, ■
. , ,
incompetence of the cervix etc.
Twins,.hydraminios.
2.
Foetal -
3.
Placental- Premature separation and placental
;
insufficiency, cephalopelvic dispropor—
tion.
,
Social;
1.
"
.
Physical labour - Women who work late in pregnancy
tend to have babies of lower
birth weight than those who have
no occupation during pregnancy
or who stop work during the
early weeks.
2
•
i .• I :
2.
Smoking - Average weight babies of smoking mothers.
is about 250 grams less t.han- babies born..
' of mother^
who ’do.'not.
’
• >-'■■.
.
. j •. ‘ •
. .
‘
'
,■ . •.
□
Others. ^
■, -
poor housing, low. economic statusj repeated
births are all associated with premature W
births
■
■;
Small for date babies.;
Low birth weight babies may be immature or small for
the period of gestation.
Small for date babies are those
having a birth weight below the 10th percentile for their
gestational age.
These are the babies where intra uterine
growth has been abnormally low and whose birth weight is
therefore low for the gestational age at which they are born.
The advantage of this classification is that it will include
.most of the babies at risk associated with intra uterine '
growth failure.
■
?
! ' .
Causes of slow intra uterine growth:
<
*
•
■ '
1.
Foetal - Poor growth potential — foetal malforma— .
tions, intra uterine infections (rubellar)’
and some forms of dwarfism where growth
failure begins before birth.
2.
Maternal — Severe malnutrition, severa toxaemia
or multiple pregnancy.
There is a
group of mothers who rather consistently
bear small for date babies.
Measurement techniques;, .
<
Measurements of fetal mortality and perinatal mortality
have frequently been carried out in which the populations.
used in the denominators consisted of either a count of
live births or a count of total births, i.e.,- live births
plus fetal deaths .of 28 of moro^weoks of gestation (still
births).
To avoid confusion it,'has'been1 urged that the ■
terminology ’’fetal death ratio" and "perinatal mortality
ratio" be reserved for those calculations in which the
3
population base is a count of live births,; the terms
"fetal death rate" and "perinatal mortality rate" should
be used when the denominator is a count of live births
plus fetal deaths of 28 or more weeks of gestation (still
births).
The rate is — in most cases - to be preferred
to the ratio.
While there are other useful measures, of
fetal and perinatal mortality, they may be given special
names in order to avoid difficulties of interpretation.
ss/29-8-1979.
aw
2
30
Corneal Xerosis (0.1)
Conjunctival Xerosis (4.3)
Bitot’s spots (3.1)
20
Angular stomatitis (5.0)
tickets (0.7)
Sparse Hair (3-8)
Protein calorie
Malnutriti on.
10
Discoloured Hair (5.3)
Basy plucka'oility of Hair'(0.9)
Moon Face (2.5)
0
Oedema (0.9)
Marasmus ----(1-3)
Nutritional Deficiency Signs in Preschool
Children. Percentage Prevalence.
3-- »
Developmental Milestones in Indian and British
Infants.
Indian.
British.
4 W e ek s .
It
8
n
12
it (
16
20.5 it
11
26
ft
22
26.3 it
32.4 11
45.1 tt
52.4 it
4 Weeks.
It
8
It
12
tl
16
tl
28
II
36
If
24
It
40
ft
44
II
48
tt
55
HOLDING THE HEAD:'
Chin slightly off ground ,
Chin at 45° angle- from ground
Chin at 45-90° angle from ground
Chin a*t 90° angle from ground
Sitting with support
Sitting without support
Standing with support .
Crawling on belly
Crawling on knees
Walking with support
Walking without support
.
Mental and Social Development.
2nd month.
The baby smiles to himself; utters cooing
sounds.
4th month.
He laughs.
6th month.
•
Cries on provocation, e.g., removal of a
toy from- his hand .
7th! month .
s
Blays with feet to moutn.
1Oth month.
2
Starts to utter a few words - "ma-ma",
"da-da-"-. .
1 year.
1-1/2 years.
Enjoys simple -tricks and games.
He imitates. Likes to play with toys.
He can speak a few definite words.
2 years.
«
Eoints to eye, nose and mouth. He desires
to feed himself. He says "no-no" to
everything.
He feeds himself. Does not wet bed. He
likes to be near other children. He
begins to enjoy group play. He arranges
his toys. He likes to dress himself.
Much laughter with play.
3 years.
-
4 years.
•
He repeats digits - one, two, three, etc.
5 years.
•
He repeats sentences; he loves his home .;
he fears dark, ghosts; he wants to assume
responsibility.
6 years.
•
He is restless;' active all the time; he
develops likes and dislikes.
7-8 years.
2
He does not like discipline; he forms
groups .
sspd/26.8.79
j
The Recommended temperatures and duration of storage for various
>
vaccines alons'.the cold chain;
1
. i
t
.
Vaccine
----- „.r . .
_ , .
Polio
1
1
|—1
i
4
ii
’1
1
. 1
:
Central 'Store 1
i
! ■'
•
'
Transport to
region»
i -20°C to +4° C
}
,
i
1
2 years at
- 20° C
■
Tetanus
(never
freeze)
!
j
■
I1/2 years at
+4 to + 8°C
Smallpox
|
1
I
3 years at
+4 to +8 °C
i
Regional
Store.
1.3 months at
1
20° C
1
1 ■
1
I
J
1
J
1
1
|
1
1
Transport to 1
district.
- __
. - ____
}
i
1
1 ...
____ 1_____
” r
i
1:3 months at
i
J : +4 to +8°C
•
. _
I .
J
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' ; 3 months at
i
* +4 to +8C>C’ •. ;
:to +8 ° C
{
1
1
: i
;
j
|
j +4 to +8°C
Rz?MDMB3R;
3 months at+4 to +8°C
}
;
-20°C to + 4°C
District
Store.
Imonth at
+4 to +8°C
I
;
i
i
1
I
i
J
1
1
i
;
+4 to +8°C
..
1
I
1 month at
J
+4 to + 8°C i
i|—
1 month at
’+4 to +8°C
’
i
I
1 month at
i
+k to +8°C
{
i
+4 to +8CC
1 month at
+4 to +8°C
•
+ 4 to + 8 ° C
—---
+4 to +8°C
____
Never use the vaccine after the expiry date on the packet;
periods are;quoted -from the date of issue.
i
•
1
i ' 3 months at
i , + 4 to +8°C
1
• 1 yeat at
’ +4 to +8°C
1 +4 to +8°C
i
1
1
_______ ____ L.
___________ L
DPT (never) I1/2 years at i
freeze) . ’ +4 to + 8°C
; +4 to +8°C
BCG
sspd.
27.8.1979.
•
I
i
j
Mobile
team
T Week at
+4 to+8°C
1 We ek at
+ 4 to + 8°C
1 Week at
+4 to + 8°C
1 Week at
+4 to + 8°C
4 Weeks at
+4 to + 8°C
VAC
Name of vaccine.
ci'y..
Effectiveness
(% protection
(2)' "
C
I
N
Period of
immunity.
E
S
Minimal age
to ue given.
Reactions.
m
.....
Slight painful local
reaction for 12-24
hours.
Long las ting> 1 0
Years
Antenatal
and at any
age.
2. DT (Diphtheria
& Tetanus Toxoi i)
Long lasting >10
years
1 month
-do-
3 • DPT (triple
vac cine)
Pertussis
approx. 4
ye ars .
1 month
Painfull local rea
ction for 24 hours.
Mild to moderate
fever for 12-24
hours.
Probaoly life
Long
1 month
1 . Tetanus Toxoid
4. Poliomyelitis
(oral)
100%
90%
None
Complicati ons.
1. Sterile injection
abscess
2. Provocation Polio
myelitis
-do 1. Local sterile inj
ection abscess
(esp.with. adsorbed
vaccine under one
month of age)•
2. Occasional ’colla
pse1 1-3 hours
after injection
(pallor, sweat,
slow pulse),uni
ver sal recovery
after an hour or
two.
3. Persistent crying
for 12 hours.
4. Febrile convuls ions.
5. Encephaliti s-very
rate (1/million).
6. Provation poliomyeliti s , j Vaccine
associated paraly
tic polio in OPV
recipients and
their contacts
1 /million( CDC*
____ 1973).____________
- 2...-
(1)
5. Smallpox
6. 3CG
(2)
90%
121__
High level for 3
years & waning
immunity for 10
years or more.
70-80%
r Jil
1.
2.
3.
4.
Birth
Papule 1 week
Ulcer 2-5 weeks
Healing by 12 weeks.
1. Accelerated reaction in tuber
culin sensitive indivicLals.
2. Deep ulcer with secondary
infection.
3. Lymphadenitis - local
4. Keloid.
6 mon
ths .
1. Slight to moderate
fever from 6th-10th
day.
2. Occasional rash.
Up to date more
than 10 years
follow-up-child
ren still have
high level .of
immunity.
8. Rubella
95%
5 years follow-up
1 year.
shows.
Shows
very little declin e
in antibody titre
(CDC 1972)
6 years observa
tions show very
little decline in
antibody titres
(CDC 1974).
(6).......
Primary vaccination
Vesicle 3 days
Pustule for 1 week
Fever for 1-2 days.
Scab at 2 weeks.
Scar at 1 month.
95%
95%
I
Birth
7. Measles
9. Mumps
(5)
1 year
Vaccinia gangrenosa
Eczema vaccinatum
Generalised vaccinia
post vaccinial encephalitis,
3/million in primary vaccina
tion (Lane 19&9).
Vaccine associated encephalit
is (1/million.)(Encephalitis
following'natural measles is
1/1000.)
1. Rash
2. Lymphadenopathy
3. Arthralgia &
transient arth
ritis.
Vaccine associated encephalitis.
1/million (CDC, 1971).
1. Occasional mild
fever.
2. Parotitis.
3. Rash.
Vaccine associated neurological
complication 1/miliion. (Enceph
alitis following natural mumps
2-4/1000) (CDC, 1974).
* Centre for Disease Control, USA.
3
3
Contraindications:
1 •
Severe febrile illnesses
'
Vaccination of persons with severe febrile illness
should generally be deferred until they have recovered.
This is to avoid superimposing adverse side effects from
the vaccine on the underlying illness or mistakenly identi
fying a complication of the illness as having been caused
by the vaccine. Minor illnesses such as mild upper respi
ratory infections do not necessarily preclude vaccination.
2.
Altered immunity
The virus replication following administration
of live, attenuated virus vaccines can be potentiated by
immune deficiency diseases and by the suppressed immune
responses that occur with leukemia, lymphoma, or generalized
malignancy or with therapy with corticosteroids, alkylating
drugs, antimetabolites, or radiation. Patients with such
conditions should not be given live attenuated virus vaccines.
3.
Poliomyelitis epidemic
During an outbreak of poliomyelitis, inoculation
with multiple ’depot' antigens should be deferred.
When an
outbreak of diphtheria, pertussis, typhoid or smallpox
occurs simultaneously with poliomyelitis, the appropriate
specific inoculation should not be deferred.
Fluid antigen
rather than 'depot' antigen should then be used.
4.
Skin disorders
Eczema and other forms of chronic dermatitis in
the individual to be vaccinated or in a household contact
are contraindications to smallpox vaccination. An inquiry
into the family history for skin disorders should always
take place before vaccination. If vaccination is required
for an individual with dermatitis because of potential
exposure in an endemic or infected area, Vaccinia Immune
Globulin (VIG) should be administered to the vaccine at the
time of vaccination. VIG will not prevent successful
vaccination.
If there is real need to vaccinate an individual
who may thus create a hazard for a household contact with
dermatitis, consideration should be given to separating the
vaccines from his contact until the vaccination lesion has
healed.
5.
Pregnancy
On grounds of a theoretical risk to the developing
fetus, live, attenuated virus vaccines are not generally given
to pregnant women.
With some of these antigens, particularly
live, attenuated rubella vaccine, pregnancy is a contraindi
cation to vaccination. With others, however, if there is a
substantial risk of exposure to natural infection, vaccine
should generally be given, taking whatever specific precautions
are indica. ted-f or example, giving vaccinia immune globulin
with smallpox vaccine.
sspd/23.8.1979
IRON DEFICIENCY ANAEMIA
IN
CHILDHOOD.
This is the commonest of the deficiency disorders
in childhood.
It is the commonest of anaemias in child
hood,- characterised by a greater proportional lowering
of haemoglobin concentration than of the red cell count.
The prevalence of this deficiency is related to
certain basic aspects of iron metabolism and nutrition.
The body of the newborn infant contains about 0.5 gms. of
iron in contrast to the iron content of the adult which
is estimated at 5.0 gms. To make up this, 4.5 gms.
discrepancy an average of 0.8 mg. of iron must be absorbed
each day during the first 15 years of life.
To this
requirement, additional iron is necessary to balance normal
losses through excretion. Hence, to maintain a positive
iron balance in childhood, 0.8-1.5 mg. must be absorbed
each day. As only about 1 0“<> of the dietary iron is absorbed
a diet containing 8-15 mg. of iron is necessary for optimum
nutrition. During the first years of life because small
quantities of iron rich foods are taken, it is often
difficult to attain these amounts.
At best, the infant is
in a precarious situation with respect to iron. For this
reason, the diet should include iron rich foodstuff.
Should the diet become inadequate or should abnormalexternal blood loss occur, anaemias ensues rapidly.
Etiology:
The etiological factors may act singly or more
comonly in combination.
0-3 months Physiological anaemia of infancy.
Anaemia
of prematurity.
Poor ante-natal storage of iron.
3-6 months Low birth weight and significant perinatal
haemorrhage are associated with decreased neonatal Hb. mass.
Anaemia due to dietary deficiency is uncommon below
the age of 6 months.
6-24 months -
Dietary deficiency is the commonest cause.
After 24 months - Blood loss is a common cause.
This may
be due to occult bleeding due to a lesion of Gut e.g.,
Peptic ulcer, Meckel's diverticulum, Polyp or Haemangioma.
In South India, it is mainly due to Helminthiasis and mal
nutrition. Anaemia could also be caused by chronoc intes
tinal blood loss induced by exposure to a heat labile
protein in whole cow's milk.
This can be prevented by
using heated or evopora.ted milk or a milk substitute.
Clinical Features:
Pallor is frequently all that is seen even with
Hb levels as low as 5-6 gms. /100 ml.
With Hb levels
less than this, child may have anorexia, irritability or
2
lethargy and frequent infections.
There maybe Tachycardia
with a soft systolic murmur heard pre cordially.
Not infre
quently the heart may be dilated.
The spleen may be
palpable 1-2 cas. below.the costal margin in 10-15% of the
cases.
The child may be obese or under weight, with other '
evidences of under nutrition.
Plica is sometimes prominent.
In long standing cases, widening of the diploe of the skull
may be expected.
Laboratory data:
R.B.Cs. show hypochromia, microcytosis, anisocytosis
and mild poikilocytosis .
There may be lenkopenia.
Bone marrow shows narmoblastic, hyperplasia with
increased pronormoblast and decreased or absent stainable
iron.
There will be low serum iron levels (less than 50
micro grams/100 ml.), and elevated iron binding capacity
(over 350 micro grams/100 ml.) and a low saturation of
transferrin protein (less than 1 6?») .
Differential Diagnosis;
be
Iron deficiency must/differentiated from
other hypo chromic microcytic anaemias.
1 .
In lead poisoning the red cells are morpho
logically similar but coarse basaphillic
stippling (punctate basophillia) is prominent.
2.
3.
The blood changes of Tahalassemia Trait
resemble those of iron deficiency.
But
characteristic alterations in the levels
of Hg b A2 and Hg b I' are usually present
. whereas they are not in iron deficiency.
4.
Thalassemia major with its pronounced
erythroblastosis and haemolytic component
should present, no diagnostic confusion.
■ -
Treatment:The principles of treatment are (a)
correction of anaemia by transfusion and
iron deficiency by iron medication.
(b)
elimination of associated ethiological
factors.
The regular response of iron deficiency anaemia to adequate
amounts of lron is an important diagnostic as well as
thirapeutic feature.
Oral administration of simple ferrous
salts (sulphates, gluconate, fermerate) provides inexpensive
and satisfactory therapy.
3
1>
There is no evidence that addition of any trace
metal, vitamin or other haematinic substance signifi
cantly increases the response to simple ferrous salts.
A daily dose of 6 mg./kg. body weight of elemental
iron in three divided doses provides an optimal amount of
iron for the stimulated bone marrow to utilise.
Ascorbic acid containing juices aid in the absorption
of iron from Gut.
Iron medications are best administered
1 hour before meals. As foodstuff containing phytic acid '
interferes with absorption of iron.
Place of parenteral Iron:
The response to parenteral iron is no more rapid or
more complete than that obtained with proper administration
of oral iron.
Parenteral iron can be given :1)
When oral preparations .are not tolerated.
2)
When it is doubted that the oral preparation
is faithfully taken over the required therapeutic
period.
Place of transfusion:
Transfusion is indicated in severe anaemia or
associated medical complications.
Infections and anorexia
would make indications for transfusion more immediate.
Packed cells are preferred if increase in concentration of
haemoglobin is immediately necessary. Along with trans
fusion, supplementation with iron medication is indicated.
I
sspd •
23*. 8.1 979
CH
ACUTE INFECTIVE DIARRHOEA IN INFANCY AND
CHILDHOOD.
.
Infective diarrhoea is the major cause of death in
infants and young children in developing countries but
also produces considerable morbidity in developed societies.
The success of the possibility of isolating the pathogen
from stools of children, even with sophisticated laboratory
techniques is only 30%.
Etiology4
1)
Bntemli infections!
(Virus, bacteria e.g.,
salmonella, shiga baccillus, staph,
protozoa, cholera and amoebic dysentery).
2)
Parenteral infection:
pyelitis.
3)
Dietary:
Overfeeding, quantitatively or qualitati
vely, for example too much carbohydrate or
f atw
4)
Oral antibioties may induce diarrhoea by direct
action on the GIT or by inhibiting the
normal bacterial flora and permitting over
growth of pathogens.
5)
Enzyme deficiencies, either primary or secondary
to diarrhoea from any other cause.
6)
Enteritis or colitis.
7)
Gastrointestinal allergy.
x
8)
,
.
Endocrine
Otitismedia, pneumonia,
Hypoadrenalism
Hyperthyroidism
Emotional upset
9)
Psychogenic
^Excitement
10)
Vitamin deficiency - Rellagra.
11)
Chemical poisoning - Arsenic sodium fluoride
cadmium, zinc.
12)
Food poisoning - Some types of mushroom newly
sprouted potatoes.
The problems' of proving, the viral, etiology have been
major as many viruses normally inhabitate the alimentary
tract of healthy children who are free of diarrhoea and very
few studies relating epidemics of diarrhoea to specific
viruses have been documentated.
Recently, virus like parti
cles have been identified by electron microscopy in epithelial
2
•4
2
cells taken at intestinal biopsy and subsequently in stool
concentrates of infants with diarrhoea, in the absence of
a recognised bacterial pathogen.
Such viral particles are
absent from control infants without diarrhoea, and dis
appear when, the diarrhoea subsides. The particular virus
involved is currently termed the 'ROTA VIRUS'.
Thus,
although a viral aetiology of infective enteritis has. not
yet been proved, it does seem .at the present time, to be
most likely.
Clinical Features:
Disinterest in feeding; associated with or without
vomiting, is the initial clue.
Diarrhoea rapidly follows
and in severe cases upto 30 stools in a day.
The stools
arc typically fluid, green in colour and have a typical
'musty' odour.
Mucus is usually present. Blood -. may or
may not be occasionally, high fever and a convulsion precede
the diarrhoea by a few hours - this is more common in the
case of shigella infection.
The effects' of these symptoms on the child are, loss
of fluid and electrolyte imbalance.
Sodium, potassium-,
chloride and bicarbonate are the particular electrolytes
lost in the diarrhoeal fluid, the concentration or osmolality
of .which may approximate that of extra cellular fluid.
Initially this fluid loss is from the extra cellular compar
tment because it is the most accessible.
Later, equili
brium with the intra.cellular compartment takes place so
that, the cells share in the dehydration. As the loss
increases, the plasma volume becomes depleted; resulting
in poor tissue perfusion with tissue hypoxia. Oliguria and .
nitrogen retention follow because of poor renal perfusion
and an associated metabolic acidosis, the result of
anaerobic metabolism, is invariably present.
Physical examination reveals signs of dehydration,
and if severe, with clinically recognisable acidosis.
Dehydration is manifested clinically by restlessness,
apathy, decreased skin turgor, depressed anterior fontenellae
and dry mucus membrane in the earlier stages. If progressive,
the pulse becomes rapid with poor pulse volume, cyanosed and
signs of peripheral circulatory failure (extremities - cold,
clammy and cyanosed) are present. Acidosis is clinically
recognised by deep sighing respirations (Kussmauls' respi
ration);
the breathe may have a sickly sweet odour.
This
combination of dehydration, circulatory failure- and acidosis
with oliguria will be fatal if not reversed rapidly by
replacement therapy. Many other febrile illness present with
vomiting and a few loose stools e.g., Meningitis, pneumonia,
septicaemia and renal tract infections. Particularly, small
infants with infective enteritis develops abdominal disten
tion rapidly .and this should be differentiated from intest
inal obstruction and peritonitis.
3
3
Managem ent;
Management of infective enteritis basically involves
"the assessment of the degree of dehydration and correct
fluid and electrolyte replacement.
Assessment of dehydration;
The very simple clue for dehydration is weight loss.
Dehydration is assessed on the basis of weight loss.
Clinical signs are not apparant if only less than 5% body
weight is lost.
Obvious signs of weight loss imply 7.8% of
body weight signs of circulatory failure - 10% of body
weight.
Weight losses in excess of 1 2% are probably not
compatible with life. For example a)
5% dehydration in an infant weighing 5 Kg. is
250 grams, which is equivalent to 250 ml. of
water and
b)
10% implies 500 grams, equivalent to 500 ml.
of water.
Classification according to
■_______ severity ._________
Clini cal
Feature s.
S.No.
Mild .
Moderate.
Severe.
1 .
Stools
5-8/day.
Frequent fluid
stool.
15 or more/
day.
2.
Dehydration
Nil
Mild-moderate.
Marked.
3.
Acidosis
Nil
No clinical
acidosis.
Present.
4.
Fever &
Vomiting.
May be.
May be.
5.
Toxicity .
Nil
Slight.
Present
invariably.
Prostration
6.
Weight Loss.
and semicomatose state.
Less
than 5%.
5%
More than
5%.
i_____
General rules for therapy;1-.
The aetiological factors eradicated if possible.
2.
The gastrointestinal tract is rested.
3.
Dehydrction, electrolyte imbalance and shock
are combated.
4.
Adjuvant therapy.
5.
Isolati on .
4
4
Treatment of mild diarrhoea.; -
No food.
Clear fluids arc given (coconut water)
(?4 Qt.water + 2 tsp. salt t /2 tsp.
sodium bicarbonate t 10 tsp. sugar).
-
Then the gradual formula is started.
-
When the stools have improved, there can
be a gradual return to full strength formula
and regular diet.
Treatment of moderate diarrhoea
-
N P 0 for 12-24 hours.
Water with added electrolytes (coconut water)
and carbohydrates are given.
Enough total fluid and electrolytes by oral
and parenteral routes to prevent progression
of dehydration and development of acidosis.
-
Diluted milk may be used for interim feeding
for 24 - 48 hours until the stools are improved.
-
Gradual return to regular feeds.
Treatment of severe diarrhoea
-
Immediate IV infusion.
-
Blood culture and stool culture.
-
Oral feeding started on 2nd day with clear
fluid having electrolytes and carbohydrates.
If oral fluids, are tolerated, dilutedmilk
be given followed by gradual return to normal
feeds.
-
Associated complications and aetiological
factor treated promptly.
Ad ,juvant s ;
■
Antibiotics and chemotherapy are used according to
the known or presumptive aetiologic organisms. Adsorbants
(kaolins) and Antispasmodies (jEpmotil) are of limited value.
Water soluable vitamins are given to combat deficiency. As
the infant improves, rarely tetany may occur and calcium
can be given psophylactically .
Trimethoprint-is not preferred
for children under the age group of 6 years because of
associated side effects.
Isolati on:
Isolation of the infected children are very important
to avoid spread and reoccurrence.
5
5
Chronic Nonspecific Diarrhoea;
Chronic nonspecific diarrhoea is an ill-defined
syndrome characterized by the appearance at 6 to 36 months
of age of persistent, loose, foul-smelling stools contain
ing mucus.
Growth and weight gain are little affected by
the chronic gastrointestinal disturbance that is frequently
associated with an intercurrent infection. Partial response
to diet and antibiotics may occur, but the administration of
diiodohydroxyquin (Diodoquin), 0.32 to 0.65 Gm, daily in two
or three divided doses is efficacious. Although the condi
tion may last several months, the prognosis is very good.
CHOLERA;
Cholera is the result of infection with one of the
pathogenic strains of cholera vibrio.
Most cases are seen
in the Indian, sub-continent but outbreaks also occur in SouthEast and Central Asia.
Infection occurs through the ingestion
of contaminated food and water.
Cholera carriers exist in
areas where the disease is endemic and maintain endemicity
through contamination of the environment.
The cholera vibrio
multiplies in the small intestine of man and produce toxins
which cause damage and desquamation to epithelium.
This
results in the exudation of large volumes of fluid and
electrolyte and the diarrhoea, dehydration and circulatory
collapse which characterise this disorder. Blood stream
invasion does not seem to occur.
The onset is usually acute with diarrhoea which rapidly
increases in severity.' Vomiting usually occurs soon after the
onset. Within 24-28 hours the stools exhibit the character
istic ’rice water1 appearances - thin whitish fluid containing
denuded epithelial cells and mucus. Dehydration rapidly occurs
and if fluid lose is not rapidly replaced,
circulatory
failure, anuria and death result.
The diagnosis which can
usually be made from the history and the typical appearance
of the stools is readily confirmed bacteriologically. Mana
gement follows precisely along the lines described above for
the severe case of infective enteritis but the acute and
explosive nature of the illness is such that intravenous
replacement must be rapid to prevent or correct circulatory
failure.
Tetracycline appears to reduce the diarrhoea and
the duration of vibrio excretion in cholera.
It is given in
a dosage of 40 mg per kg per day in 4 divided doses.
Cholera
vaccination is indicated for persons intending to spend time
in an endemic area.
The immunity is however short probably less than 4 months.
sspd .
29.8.1 979 .
CrV'^-3
ORAI, FLUID - A SIMPLE WEAPON AGAINST DEHYDRATION
IN DIARRHOEA. .
By
N.F. Pierce &
N. Hirschhorn.
•> a •
"Oral rehydration therapy provides an
effective weapon in the fight against
acute diarrhoeal diseases, including
cholera. Recently, this me.thod of
treatment has been used in various
situations and remarkable results in
terms of controlling the .severity of
diarrhoea and mortality due to acute
diarrhoea were obtained."
The aim of oral therapy is to prevent and treat
dehydration, which is the main complication in any diarrhoeal
illness.
The treatment involves prompt replacement of faecal
losses of water end electrolytes by an oral glucose-electrolyte solution. However, to understand the importance of oral
therapy one must have a comprehensive view of the problem
presented by diarrhoea.
Why is diarrhoea a problem?
Acute watery diarrhoea due to infections is second only
in incidence to infections of the respiratory tract. In
some developing nations diarrhoeal attacks may occur as. fre
quently as once ’every month during a child's second year of
life.
In these countries acute diarrhoea is probably the
most common cause of death;
'
. *'
■<->
’ '■
it is certainly the major cause of mortality in
small children. Cumulative mortalities of 25-40% among
children up to the age of 5 years are common in developing
nations; 40% or more of these deaths, which are caused by
dehydration or chronic malnutrition, are associated with
acute diarrhoea.
Malnutrition is often initiated by acute
diarrhoea and is aggravated by each subsequent attack of
diarrhoea.
■ Thus in most developing countries, owing to the
frequency of diarrhoeal illness (especially in young
children) and the resulting morbidity and mortality, acute
diarrhoea is a considerable health problem and every effort
is needed to bring it under control and to prevent serious
consequences.
What causes diarrhoea and the ensuing dehydration?
Acute watery diarrhoea is caused by a variety of
infectious agents (see Table 1), whose actions alter
intestinal function by different mechanisms. For example,
viruses replicate within mucosal cells, produce patchy but
transient mucosal damage, and cause water and electrolyte
2
2
secretion which is greatest during the healing phade. In
contrast bacteria like Vibrio cholerae and enterotoxigenic
strains of Escherichia coli are not invasive but .colonize
the mucosal surface and secrete an enterotoxin, which
causes mucosal secretion without any apparent damage to
mucosal cells.
Although these mechanisms differ, the
clinical and biochemical effects produced are similar in
several important aspects:
Infectious agents that commonly
cause acute water diarrhoea.
Bacteria
Salmonella species
Shigella species 1
Enterotoxigenic Escherichia coli
Vibrio cholerae
Non-cholera vibrios
Vibrio parahaemolyticus
Viruses
Re0-like virus •
Norwalk agent.
1 May also cause dysentery without watery
diarrhoea.
(l) Normally the small bowel secretes, rather than
absorbs, water and electrolytes.
In severe diarrhoeal
diseases, the volume secreted is large end cannot be fully
absorbed by the colon, so that watery diarrhoea continues
even if oral intake stops.
In mild disease, diarrhoea may
occur only when there is food and liquid intake, since the
volume of intestinally secreted fluid is small.
(2) Diarrhoeal stool is usually isotonic with
plasma but may differ greatly from plasma in' electrolyte
content (Table 2). Potassium and bicarbonate concentrations
are usually higher than plasma; sodium concentration may be
similar to plasma or lower.
In genera.l, sodium content
approaches that in plasma when stool is watery and the rate
of loss exceeds 50 ml per kg of body weight in 24 hours.
Sodium content is lower when the rate of loss is less than
this, and when faecal matter is present and food intake-is
continued.
(3) Disaccharidase enzymes of the bowel mucosa
(especially lactase) are often damaged so that the ingestion
of lactose in cow's milk by infants with lactase deficiency
makes the diarrhoea worse. The lactose is not absorbed in
the small bowel but passes into the colon along with the'
additional water required to maintain isotonicity.' In the
colon the lactose is fermented into smaller fragments,
including organic acids, which apparently further increase
the stool volume by their osmotic activity.
3
3
(4) Acute diarrhoea usually lasts 1 to 7 days end
ends when the infection is controlled by the host's
defences.
In some cases (e.g., cholera and shigellosis),
the duration may be shortened by antibiotics.
Chronic or
recurrent diarrhoea usually indicates intestinal abnor
malities due to malnutrition, disaccharidase deficiency,
or parasitism.
Dehydration is the result of fluid loss from the
body.
With diarrhoea this loss occurs almost entirely
from the extracellular fluid compartment and leads to a
progressive diminution of blood volume.
When this fluid
loss is less than 5/fa of the body weight, thirst is the
only sign of dehydration (apart from the diarrhoea).
When the deficit exceeds 5/*> of the body weight, the
following symptoms and signs develop rapidly: tachycardia,
decreased skin turgor, postural hypotension, irritability,
oliguria or anuria, severe thirst, hypotension, and stupor
or coma.
Shock occurs when the deficit equals about 10%
of the body weight; greater losses cause death.
It is
important to note that half of this lethal deficit can
develop before the usually recognised signs of dehydration
appear.
Vomiting occurs but may not necessarily be due to
fluid deficit.
Some children develop serious hypoglycaemia,
partly owing to fasting; this may cause'coma, convulsions,
end even death.
Hypertonic dehydration, which is due to relatively
greater losses of water than salt, may occur in a few
infants and, when serious, may cause coma or convulsions
and death.
This problem may occur when infants with
diarrhoea are fed large amounts of cow's milk; larger
volumes of stool with lower sodium content are then' produced
and a greater deficit of water than salt results. Hyper
tonic dehydration is relatively uncommon in developing
countries, probably because more children are breast-fed
(breast milk has a lower solute load than cow's milk andthe feeding volumes are smaller) and because cow's milk,
when used, is very much diluted, thus providing extra
water to replace the stool losses.
Hypotonic dehydration (serum sodium concentration
less than 130 mmol/l) may occur when stool loss is replaced
orally by plain water. Hypotonic dehydration causes few .
specific symptoms and is usually much less dangerous than
hypertonic dehydration.
Long-term effects of repeated diarrhoea*
The long-term effects of repeated diarrhoeal attacks
are largely nutritional, children under the age of 3 years
being the most frequent victims.,. Watery diarrhoea causes
a negative nitrogen balance, which reflects protein cata
bolism due to the infection and to fasting. When the
quality and quantity of a patient's food intake is marginal,
4
4
the protein losses during diarrhoeal attacks (and during
other infections) are only slowly regained and the weight
lost is only gradually recovered.
The cumulative result is
restricted growth and increasing protein deficiency.
If
this process is repeated, it is eventually complicated and
accelerated by chronic diarrhoea and dietary malabsorption
associated with atrophy of the small bowel mucosa.
The
final outcome, if not death from an intercurrent infection,
is death with the clinical picutre of protein-energy
malnutritorj-
Major objectives in treatment;
The two major objectives in treating acute diarrhoea
are :
- very early replacement of water and electrolyte
losses to prevent or treat dehydration.
- maintenance of adequate nutrition to prevent
malnutrition.
Early replacement therapy should begin promptly
after diarrhoea starts.
Early treatment has three important
advantages.
First, it avoids the risk of death from severe
dehydration.
Second, it minimizes the symptoms associated
with increasing water and electrolyte deficit, e.g., vomiting
anorexia, lethargy, or coma, which interfere with continued
feeding. And third, the treatment needed is simpler because
it is given while two important homeostatic mechanisms
’
(thirst and renal function) are still intact.
When an oral
glucose-electrolyte solution is taken under these conditions,thirst is one important guide to the amount required,
' '
and normal
renal function permits the excretion of any excess of water
or salt.
Maintaining nutrition during acute diarrhoea is
essential to prevent the adverse effects.of fasting. More-?.
over, nutrition can be maintained because the gut remains
able to absorb a variety of nutrients, -lactose being the
most common exception. Apart from lactose, usually no
other dietary restriction is needed.
In fact, there is no
physiological basis to the common belief that the.bowel
should be "rested" during acute diarrhoea.
The primary goal of treatment is not the immediate
termination of diarrhoea.
Although shortening the duration
of diarrhoea would be desirable, most attempts are either
ineffective (such .as' "routine" .antibiotics or "antidiarrhoeal
mixtures") or they interfere with goals of higher priority.
For example, fasting, may diminish stool loss but obviously
prevents maintenance of nutrition. Moreover, treatment
aimed at stopping diarrhoea often diverts attention from
the major objective. - fluid and electrolyte replacements.
until a serious deficit has developed.
5
:
6
:
Other sugars, especially those that yield glucose
when broken down in the gut, may be useful for enhancing
sa.lt and water absorption when glucose is not available.
If their breakdown were incomplete, however, their effect
would be reduced.
A sucrose-salt solution containing 40 g
sucrose per litre, for example, has been almost as
effective as the glucose-salt solution for treating patients
above the age of 5 years with severe cholera, and other
diarrhoeal diseases (D.L. Palmer et al. , unpublished
observations).
A.
NORMAL SMALL INTESTINE
INTAKE:
RESULT:
Isotonic
salt
Enhanced
absorption
(Sodium + Water)
Moderate
absorpti on
(Sodium 4- Water)
B. ACUTE WATERY DIARRHOEA
INTAKE:
Nothing
V
V4
RESULT:
Diarrhoea
Diarrhoea
worsens
Dehydration
develops.
Dehydration
develops.
Isotonic
se.lt
Isotonic
salt + Glucose
V
Diarrhoea
Hydration is
maintained or
corrected
Eig. 1 . Effect of glucose on intestinal absorption of
salt and water (a) in the normal small intestine
and (b) during acute watery diarrhoea.
(See text
for details).
7
7
For the successful implementation of oral thera.py
in local health centres and even in homes, the method
employed must be uniform and sinple.
The use of an
oral solution based on a single formula is essential
in such an approach, the advantages outweighing any
possible value of solutions of varying composition for use
in different age groups or phases of treatment. Moreover,
it should be emphasised that the water and electrolyte
requirements are reasonably constant (and can thus be met
by a single solution) in those clinical situations in
which large amounts have to be given.
Table 2 and the accompanying box show the
composition of a widely tested and effective glucoseelectrolyte solution, which is approximately isotonic
with plasma; it contains sodium and glucose in an
approximately equimolar ratio and sufficient potassium and
bicarbonate to replace a major portion of stool losses.
The sodium concentration is sufficient to correct an intial
isotonic deficit a.nd to replace continuing stool losses
when the rate of loss is moderate or severe. Normal
renal function is essential so that ary excess of salt or
water may be excreted.
In children with mild diarrhoea
the stool sodium concentration is often lower than that in
the oral solution; the water requirements of such patients
are also met by the water provided in continued oral feedings.
Table 2.
Electrolyte content of stool in acute
watery diarrhoea compared with that of
normal plasma, and the electrolyte and
glucose content of oral fluid.
Na +
K +
CI-
HCO-
Cholera stool
adults
children^ c5 years)
Enteritis stool
children(<5 years)
Normal plasma
140
1 01
13
27
1 04
92
44
32
56
1 42
25
4.5
55
1 05
14
25
Oral fluid b
90
20
80
30 Glucose 111
a - Values, which are averages from several studies,
are expressed in mmol/l.
Widest variations are
seen in Na. and C1 .content of enteritis stool in
children.
Sodium content drops rapidly from mean
values above 90 mmol/l to a mean of about 60 mmol/1
when the rate of stool loss falls below 50 ml/24
h per kg of body weight.
b - Values are expressed in mmol/l.
The composition of
oral fluid in grams per litre is given in the
accompanying box.
8
8
Table 3:
Guidelines for orel fluid, therapy,
Amount given.
1. Rehydration
A. For mild dehydration
(on examination,
normal or diminished
skin turgor.or sunken
fontanelle; patient
able to drink)
B. -For severe dehydra
tion (hypotension,
shock, stupor or
coma, absent radial
pulse)
2. Maintenance
A. For mild continuing
diarrhoea(less than
1 stool every 2
hours)
B...For severe conti
nuing diarrhoea.
a
Time required.
50-120 ml/kg, the larger
amount when turgor is
diminished.
Encourage
patients to drink until
they refuse. Adults may
need up to 1000 ml per
hour.
If patients tire
or drinking, use a con
tinuous nasogastric
infusion.
100 ml/kg intravenous
poly-electrolyte solu
tion ( e.g., Ringer’s
lactate1'1') , or normal
saline if'nothing else
is available.
Do not
use oral therapy until
shock is corrected.
U sually
4-6
hours.
Give half
rapidly
(30-60 minu
tes), the
remainder in
3-6 hours.
100-200 ml/kg oral
soluti on.
Every 24
hours, until
diarrhoea
stop s.
15 ml/kg oral solution,
sometimes more. Observe
carefully to confirm
adequate maintenance of
hydration.
Every hour,
until dia
rrhoea
becomes
mild or
stops.
An ideal polyelectrolyte solution is DTS
(diarrhoea treatment solution), which is
recommended by WHO.
If half-strength
Darrow’s solution with. 2.5^° glucose is
used, give 150 ml/kg.
9
9
Instructions for use;
The oral solution should be made fresh daily.
It
is practical to use foil packets containing pre-weighed
mixtures.of glucose and the salts tobe dissolved in a
specified volume of drinking water.
These packets can be
safely stored as long as they are moisture proof.
The guidelines for the use of oral therapy are simple
(Table 3)» The limits of its usefulness will be described
below. It may be used as the sole therapy to rehydrate
patients with mild or moderate dehydration (up to 7% loss
of body weight) and to maintain hydration in almost all
patients, after rehydration,until the diarrhoea stops.
In general, most patients who are awake and able to drink
well can be treated by the oral route.
Thirst is a very useful guide to the amount of oral
solution required.
Rehydration is often achieved by
allowing the patient to drink as much fluid as desired,
but patients with very rapid stool loss may have to be
encouraged to drink sufficient fluid. Excess fluid intake
may cause puffy eyelids (this is harmless), in which case
the oral solution should be stopped until this finding
disappears.
If patients tire of drinking, the fluid can.
easily be given by continuous nasogastric infusion.
If
the initial dehydration is severe, rehydration must be.
performed intravenously with an isotonic polyelectrolyte
solution (or normal saline if only that is available),
after which the oral solution may be used for maintenance.
The maintenance requirements of oral fluid, after'
rehydration, should equal the rate of continuing stool loss,
Tor adults with severe diarrhoea (e.g., in cholera),
measurement of stool losses, separate from urine, by the
use of a cholera cot helps to determine the maintenance
requirements.
Since accurate stool collections are not
possible with infants, the stool losses should be carefully
estimated by frequent observation of diapers.
Stool
losses are usually greatest in the first 24 hours of
treatment and decrease steadily thereafter.
Patients with
mild diarrhoea may be given oral fluid for home use,
returning each day for reexamination and more fluid, if
needed.
Those with frequent diarrhoea should be observed
every 3-6 hours to determine whether oral intake is
sufficient and hydration appears satisfactory.
Valuable
signs of adequate hydration include normal skin turgor,
normal urine flow, normal pulse rate and volume, and a
sense of well-being.
If signs of dehydration reappear
despite vigorous oral replacement, parenteral fluid
therapy should be started.
'
Patients given the oral solution may vomit.
This
occurs most commonly when oral therapy is first begun.
Unless vomiting is severe and repeated, oral therapy should
3
10
10
be continued, small amounts being given frequently.
The
volume of fluid lost by vomiting is usually a very small
portion of that taken and retained by the patient.
If possible, pe.ti'ents x-fith diarrhoea should conti
nue to eat and drink to maintain their nutrition.
Drinking of the oral solution can be alternated with
food intake. Breast-fed children should continue to be
nursed; those given cow's milk should take reduced amounts
limited to 150 ml every 4 hours. If the diarrhoea worsens
markedly, cow's milk should be stopped and other protein
foods used.
Staple foods such as cereals, bananas, cooked
legumes (lentils, chick peas, etc.), and potatoes can be
continued during the diarrhoea. Adults should resume a
normal diet of well-cooked food as soon as their appetite
returns 4 When the required amounts of oral fluid have
been taken, patients may be given additional water if
they desire it.
Antibiotics should not be given routinely. Oral
tetracycline shortens the duration of diarrhoea in
cholera. Antibiotics are also effective in severe
shigellosis, but the appropriate choice can be made only
by testing the sensitivity of the organism in vitro.
There are no other adjuncts to the treatment of
diarrhoea that are of proven value.
Limitations :
There are some circumstances in which oral therapy is
not successful or has not been fully tested and therefore
cannot be recommended.
In these situations, water and
electrolyte replacement should be given parenterally:
Patients with severe dehydration, often with signs
of shock.
Such patients need very rapid water and salt
replacement intravenously. Oral therapy is too slow.
Patients who cannot drink because of fatigue, stupor,
or coma.
The oral solution can be given to such patients
by nasogastric tube.
Patients with prolonged oliguria or anuria, but not
those with brief oliguria or anuria which often accompanies
dehydration.
The former require precise administration of
water and electrolytes, usually parenterally.
Patients with severe and sustained vomiting.
.About 3% of patients with acute diarrhoea have
serious glucose malabsorption.
In these patients oral
therapy causes a marked increase in stool volume, the stool
containing large amounts of glucose, and the dehydration
worsens.
11
11
Patients with very severe diarrhoea (e.g., adults
losing more than 800 ml of stool per hour) may be unable
to drink enough fluid to replace the continuing losses.
Oral therapy has not been evaluated in premature
infants or in babies less than one month old.
Oral therapy has been used with success to treat
thousands of attacks of mild, and moderate acute diarrhoea
in children and adults in many parts of the world, and its
usefulness has been carefully documented in a number of
reported studies.
When cholera and infantile diarrhoea were
treated by this method by experienced workers, there was
almost no mortality and the need for intravenous fluids
was reduced by 70-90%. When oral therapy was used under
the worst possible conditions to treat cholera among
refugees from Bangladesh, most of the treatment being
given by untrained family members, mortality was only 3%
and half of these deaths occurred before the treatment could
be given.
These observations and the rationale on which this
approach to treatment is based argue strongly in favour
of oral therapy as the single most effective therapeutic
tool in the treatment of acute diarrhoeal disease.
Note : -
While intravenous rehydration is the best form of
treatment when patients are in shock and are
unable to drink, oral rehydratioh is the best
procedure for treating mild and moderate dehydra
tion and for preventing severe dehydration.
The
oral rehydration treatment of acute diarrhoea can
be carried out in the homes of patients and thus
saves expensive injectable fluids and hospital
costs. The numerous instances of the use of
Intravenous fluids when the oral fluid could
easily have been justified are an examply of
waste.
sspd.
26.8.1979.
Convulsions in Childhood.
'
Convulsive phenomena are..more common, in children- and
occur with a wide’ variety of CNS disorders,.
While the incidence in adults is less than 1%, the child suffers an ,. ' '
incidence of 1%,
Convulsions should be regarded-as at
symptom and not as5ji ^disease entity«
There is a broad
spectrum between.those in whom a seizure may be-provoked
only after the administration of analeptic drugs and those
whose seizures are spontaneous'.
In this latter group, the.,
provoking stimuli are yet too subtle to be determined by-:.
present methods.:
Seizures may be provoked in certain individuals by hyperventilation, television, flickering of
light, sunlight, sky, fire, water and even paint
' :
The basic, .pathophysiology involves abnormal-neuronal
discharge-Which- may be, recorded electrically as a seizure
pattern on the E.E.G-,., and are manifested .clinically as
convulsions.
Incidence. .
. .1 .
More .Common, during first 2 years.than at any other
period of lif e.
.- ...
' " '
' ■.. ...
f-’"'
.Intra cranial birth -injuries-,In very young infants -^effects of'anoxia and’haemorrhage.
Congenital defects of brain, are
" ■’ ’’
■the most frequent causes.
In later part of infancy and 0
early childhood. . ..
)
'
' ' .
...
The less.frequent eaus.es - .
;
.
(
....
.' ...
.‘
... .
.
'
"
Acute infection.'1 .
(Extra, cranial or "intracranial) .. ,.
Tetany,
’’ . .
' . u ■
Idiopathic epilepsy,
-.her
Hypoglycaemia,,
' ’ .-if-;. A.
Brain'-tumors,'
Renal insufficiency--,,- v. . -Poisoning,
Asphyxia, ...
Spontaneous intra cranial ■
. haemorrhage, •• •
'■ pr> ’ ■ Thrombosis,
Post-natal trauma,
Hypocalcemia.-.
’"Mid’ childhood., ,convulsidhs-due,to--'acute. extra . cranial.
infection are not frequent.... Idiopathic epilep'sy is the commonest and it appears at the age of 3 years. ’■ Other
causes in the post infancy period - .congenital defects, .of ;
..brain, residual cerebral damage due to early trauma >. infect ion
lead poisoning, brain tumors, acute and chronic glomerulo- ~
nephritis degenerative disease of brain, drug ingestion.
2
■
2
Convulsion in newborn:
A clinical seizure at any age is associated with a
paroxysmal bursts of electrical activity in CNS.
In
newborn, electrical activity of cerebral hemisphere is
poorly developed but subcortical rhythm are present.
Mass myoclonic movements have been said to cuur in utero,
but the tonic and clonic movement that characterise the
grandmal seizures are rarely apparent during the first
few weeks of life.
. The low incidence of G.M seizure
reported during neonatal period probably reflects both
the poor development of cerebral hemisphere and lack of
uniformity in recognizing or classifying seizures or
their equivalents.
After an-episode of acute anoxia, a convulsion may
take the form of a tonic spasm preceded by a few clonic
jerks• The E.E.G becomes flattened.
Focal seizures may be associated with irregular jerky""movements and nystagmus or staring, pallor and hypotonia,
the E.E.G showing paroxysmal bursts of multiple spike and
slow wave discharge.
—
In some instances respiration becomes slow. and.
irregular with periods of apnoea and a feeble cry.
The
neck becomes rigid, pupils dilate and the child drools.
Alteration of E.E.G may also oc.pur with slight movement of
fingers, toes or eyelids with a change in colour or with
chewing. ■ "
.
The presence of a seizure suggests cerebral insult and
should alert the physician.'
'The possible material use of
drugs should be considered.
A disorder of amino acid
matabolism should be excluded through chromatography of
urine or searum.
Trial by pyridoxine and examination of ...'
urine for 'Maple syrup urine disease1 may be life saving.
Earlier the onset,' better the prognosis - unless
other associated complication intervenes,.
The outlook
is poor if heart rate is slow or if symptoms persists for
more than 72 hours.
Supportive care is the primary treatment and management.
This includes prevention of shock, maintenance of adequate
air way and sedation*
Diazepam and phenobenbital are the
drugs of choice.
Acute convulsions in infants and children:
Generalised tonic and clonic convulsions similar to
grandmal attack of epilepsy are by far the most common. :
Practically speaking all seizures resulting from extra
cranial disorders are of this type.
■ -
3
1
3.5$ of children have febrile convulsions most of which
occur after first 6 months of life but within 2 to 3 years.
The incidence decreases upto 6-8 years after which such
seizures are rare.
Males are more prone to this type and
there appears to be an increased susceptibility in families.
Febrile convulsion occur at the peak of the febril illness.
In late infancy and early childhood most of the
seizures follow an acute febrile illness.
Child who had
an early episode should be examined thoroughly for the
possible causes.
Such disorders as Tetany, lead encepha- .
lopathy, Intra cranial haemorrhage or injury or tumor,
poisoning strychnine, hypoglycemia, asphyxia, cerebral sinus
thrombosis, acute nephritis and epilepsy should be considered.
Age of the child, complete history and complete physical”” '
examination including fundoscopy will help to arrive at a
diagnosis.
Determination of serum calcium,' blood sugar arid BUN
(Blood urea nitrogen) will help in the differentiation of
hypocalcaemic Tetany, hypoglycemia.and acute nephritis
respectively*
Coexisting hypertension, albuminuria and
cylindruria. are evidences of nephritis.
In lead poisoning, X-Ray reveals lead line in long
bones, multiple recent or healed fractures as in the
battered child syndrome or thickening of the skull or
widening.of sutures in case of raised intra cranial tension.
In case of infection, the type of infection (extra
cranial or intra cranial) should be determined.
Treatment:
In case of febrile convulsion treatment is 3 mg/kg
phenobarbital and lowering of temperature is the ideal
thing to do.
After other causes of convulsion has been
excluded a trial of pyridoxine would help.
Prognosis;
Every episode of convulsion increases the chances of
nonfebrile epilepsy.
Developing Idiopathic epilepsy, is a high possibility
in children who have more than 5 episodes in a period of
12 months or a single seizure more than an hour or persist
ing E.E.G abnormalities.
Approximately 25$ of epileptics
give a history of febrile convulsions.
There is a wide range of opinions about starting daily
anti-convulsant therapy.
Some suggest anti-convulsant
treatment after the first afebrile seizure and others
suggest daily anti-convulsant therapy after the first
4
.■
f--.
4
attack of convulsion (febrile or afebrile), because a
great majority of epileptic give a h/o febrile convul
sions.
Any way both should, be kept in mind before
•starting the daily anti-convulsant treatment.
Consulta
tion with child’s parents is very necessary to avoid
unnecessary complications.
Disorders cSimulating epilepsy;
- Norcolepsy.
- Abdominal epilepsy.
- Breath holding.
- Hysterical fits.
- Syncope.
- Apnoc.ic episodes during swimming
-Migraine (Hemicraina).
ss.
28-8-1979
CH
ETIOLOGIC CLASSIFICATION OF CONVULSIVE DISORDERS.
I.
ACUTE OR NONRECURRENT FORMS:
"Febrile convulsions" (e.g. at onset of acute extra
cranial infections or in association with high environmen
tal temperatures).
Intracranial infections (e.g. acute meningitis,
encephalitis, sinus thrombophlebitis, cerebral abscess,
tetanus, malaria, typhus fever).
Intracranial hemorrhage (e.g,. from birth or other
trauma, hemorrhagic disease, rupture of defective vessels
sickle cell disease).
Toxic:
1. Convulsant drugs (e.g. aminophylline, antihistamines,
camphor, propoxyphene, pentylenetetrazol, phenothia
sine, hexachlorophene, corticosteroids, strychnine
and thujone).
' 2 . Tetanus .
3. Lead encephalopathy.
4. Shigellosis, salmonellosis.
Anoxic (e.g. sudden severe asphyxia, inhalation anesthesia)
Metabolic or nutritional (e.g. acute hypocalcemic and •
hypomagnesemic tetany, hyponatremia and hypernatremia,
alkalosis, therapeutic hypoglycemia, pyridoxine deficiency,
phenylketonuria, copper deficiency (Menkes), maple syrup
urine disease, hyperammonemia, argininuria, argininosuccinic
aciduria, hyperly s inemia, tyrosinemia., glycinemia)
■ —
Organic acidurias (propionic, lactic, green acyl dehydrogenase
deficiency)
Acute cerebral edema (e.g. in acute glomerulonephritis or
allergic edema of the brain)
Brain tumor
Miscellaneous (porphyria, systemic lupus erythematosus)
II. CHRONIC OR RECURRENT FORMS;
Epilepsy:
/
1. Idiopathic (primary, cryptogenic, essential or
genuine epilepsy)
- •
a) Hereditary or genetic type
.
b) Nongenetic .or acquired idiopathic type (?) .
2.
Organic (secondary or symptomatic epilepsy-with
residual brain damage from previous focal or
diffuse injuries)
2
2
:
a) Post-traumatic (e.g., from direct laceration
- of brain tissue)
b) Posthemorrhagic (e.g., from injury at birth or
later, from hemorrhagic diseases, pachymeningitis,
rupture of miliary aneurysm) .... ... .
.
....
c)
Postanoxic (e.g.,. from severe asphyxia neonatorum)
d)
Postinfectious (e.g., following encephalitis, .
meningitis, sinus thrombophelebitis or abscess)
e)
Post-toxic (e.g., kernicterus, encephalopathy
following lead, arsenic or other chronic poisoning)
f)
Degenerative (e.g., "idiopathic atrophy," cerebromacular
degeneration, encephalitis periaxialis diffusa,
intracranial neurofibromatosis, incontinentia pigmenti)
S) Congenital (e.g., cerebral aplasia, porencephaly,
tuberous sclerosis, hydrocephalus, vascular anomalies
such as the Sturge-Weber type and arteriovenous
aneurysms)
h) Parasitic brain disease (cysticercosis, toxoplasmosis,
syphils)
i) Posthypoglycemic injury.
3• Sensory (reading,
induced)
touch,light, sound, music,
self
Epilepsy-simulating states:
Narcolepsy and cataplexy
Hysteria ("psychogenic epilepsy")
Tetany;
1. Hypocalcemic (e.g., idiopathic, postoperative,
neonatal, vitamin D deficiency, deficient intestinal
absorption)
2. Of alkalosis (e.g., vomiting, administration of
bicarbonate, hyperventilation)
Hypoglycemic states:
1. Hyperinsulinism (e.g., tumor or hyperplasia of
islets of Langerhans)
2. Hypopituitarism (e.g., deficiency of adrenocorti
cotropic, thyrotropic and growth hormones)
3. Adrenocortical insufficiency. ...... .... .
4. Hepatic disorders (e.g., von Gierke's disease)
5. Miscellaneous (e.g., leucine-induced, idiopathic
ketotic)
Uremia
"Cerebral" allergy
Cardiovascular dysfunction or syncopal attacks (e.g., simple
fainting attacks, Stokes-Adams syndrome, hyperactive
carotid sinus reflex)
Migraine•
sspd.
. 26 .8.1979 .
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