Concepts, Aims, Scope Of Preventive Paediatrics,

Maternal Health and Its Influences On Child Health,

Antenatal Aspects Of Preventive Paediatrics
SL.NO CONTENT

1. INTRODUCTION

2. OBJECTIVES

i. GENERAL: By the end of the class the students will have indepth
knowledge about “concept, aims, scope of preventive paediatrics,
maternal health and its influences on child health, antenatal aspects of
preventive paediatrics”
3.
ii. SPECIFIC: By the end of the class the students will be able to- a
a) state the aims, steps and types of preventive paediatrics

b) explain prevention in paediatrics

c) state the Barker Hypothesis

d) discuss the maternal health and its influences on child health

e) discuss the antenatal and post natal care of the mother and child

4. TERMINOLOGIES:

a) amniocentesis

b) chorion biopsy

c) fetoscopy

d) genetic counselling

e) mortality

f) morbidity

g) tetanus neonatorum

h) toxaemia

5. - Concept of preventive paediatrics

6. - Aims, Steps and Types of preventive paediatrics

7. - prevention in preventive paediatrics

8. - Barker Hypothesis
SL. CONTENT
No.

9.
- Need for early prevention
10.
- Nurse as an integral part

-Social paediatrics
11.
12. -Maternal health and its influences on child health

13. i) Antenatal care

- antenatal services

ii) intranatal care

iii) postnatal care

14. Antenatal preventive paediatrics

15. CONCLUSION

16. JOURNAL ABSTRACT

17. BIBLIOGRAPHY
INTRODUCTION

Today paediatrics is regarded as the medical science which enables an

anticipated newborn to grow into a healthy adult, useful to the society. In
other words, it is a study of the child from very conception through childhood.

Paediatrics, therefore, is concerned with the health of infants, children and

adolescents, their growth and development, and their attaining full potential
as adults.

Child health depends upon preventive care. Majority of the child health
problems are preventable. Preventive paediatrics is a specialized area of child
health comprises efforts to avert rather than cure disease and disabilities.

TERMINOLOGIES:

1. Amniocentesis- surgical transabdominal or transcervical penetration of

the uterus for aspiration of amniotic fluid.
2. Chorion biopsy- removal and examination of the outermost tissue of the
fetal membrane
3. Fetoscopy- viewing the fetus in utero through an endoscope.
4. Genetic counselling- it denotes informing the individual or families about
the present and future possible genetic disorders and various options
available for safeguarding from recurrence of such a disorder or
minimizing its adverse effects.
5. Mortality- date rate
6. Morbidity- indicative of disease
7. Tetanus neonatorum- tetanus of very young infants usually due to
umbilical infection
8. Toxaemia- the condition resulting from the spread of bacterial products
(toxins) by the blood stream.

DEFINITION:

Preventive paediatrics has been defined as “The prevention of disease

and promotion of physical, mental and social wellbeing of children with the
aim of attaining a positive health”.
CONCEPT OF PREVENTIVE PAEDIATRIC

Preventive paediatrics consists of efforts by the health care provider to

avoid, rather than cure disease and disability in children through health
promotion and prevention activities. This includes good sanitation, effective
public health measures and immunizations. The concept of health promotion
has been expanded to include the emotional and mental well being of children
and families.

Preventive health care is a continuum that includes primary, secondary

and tertiary prevention. Primary preventive measures are directed at avoiding
disorders before they begin. E.g.; chlorination of water, addition of iodine to
salt, tetanus immunization, and counselling the parents about keeping poisons
and drugs out of reach of children.

Secondary preventive measures are that in which a condition is

identified early and effective treatment is instituted to cure and prevent
further progress of the illness.

Tertiary prevention is directed at ameliorating or halting disabilities from

established diseases. An example is providing physiotherapy to a patient of
poliomyelitis.

AIMS OF PREVENTIVE PAEDIATRICS ARE-

Prevention of disease and promotion of physical, mental and social well-
being of children so that each child may achieve the genetic potential with
which he/she is born.
To achieve these aims, hospitals for children have adopted the strategy
of “primary health care” to improve child health care through such activities as
growth monitoring, oral rehydration, nutritional surveillance, promotion of
breast feeding, immunization, community feeding, regular health check-ups,
etc. primary health care with its potential for vastly increased coverage
through an integrated system of service delivery is increasingly looked upon as
the best solution to reach millions of children, especially those who are most in
need of preventive and curative services.
STEPS IN PREVENTIVE PAEDIATRICS:
1. Essential newborn care is the first step towards establishing an effective
chain to reduce infant mortality and increase the National output.
2. Promotion of breast-feeding in the community essentially protects
children from their two biggest enemies i.e., infection and malnutrition.
3. Organisation, planning and execution of immunization services are the
cardinal preventive measures for control of many life threatening or
disabling communicable illnesses.
4. Growth monitoring is considered to be the fundamental tool for early
detection of childhood morbidity.
5. Community child health services should seek to promote good health,
both in the present and for the future, by the means of surveillance,
immunization, health education and counselling for children and
parents.
6. Child health clinics should form part of the primary health care. Earlier
their scope has been present in scattered manner, named as well baby
clinics, under five clinics etc. over the years their scope has broadened to
cover all aspects of paediatric and adolescent care.

TYPES OF PREVENTIVE PAEDIATRICS:

1) Antenatal preventive paediatrics

2) Postnatal preventive paediatrics
Antenatal preventive paediatrics includes care of the pregnant mothers
with adequate nutrition, prevention of communicable diseases,
preparation of the mother for delivery, breastfeeding and mothercraft
training. Pre-pregnant health status of the mother also influences the
child health.

Postnatal preventive paediatrics includes promotion of breastfeeding,

introduction of complementary feeding in appropriate age,
immunization, prevention of accidents, tender loving care with
emotional security, growth monitoring, periodic medical supervision and
health check-ups, psychological assessment, etc.
PREVENTION IN PAEDIATRICS: SPECIFIC ISSUES
Nature and nurture both play an active role in helping a child in
accomplishing his potential. In order to help the child to achieve his optimum,
it is essential to identify the factors, both hereditary and environmental that
may influence his health, growth and development. Following this, attempt can
be made to encourage beneficial influences and discourage or avoid the
harmful ones. Environment for the child may be constituted by the intrauterine
milieu, home and outside world. Environmental factors are easily ameliorable
and hereditary factors too are no longer considered to be unalterable. Modern
techniques have also helped in increased awareness of the effects of abnormal
genes and chromosomes.

BARKER HYPOTHESIS: FETAL LIFE AND ADULT DISEASES

Recent research indicates that most of the diseases in adults and elderly
have a fetal correlate. David J. Barker and his colleagues are involved in
identifying various risk factors during pregnancy and infancy, which predispose
the fetus or infant to disease in later life.
Barker suggested that fetal under nutrition operating in different
trimesters would have different effects on birth weight and subsequent
disease pattern.
-First trimester under nutrition: It may result into the birth of
symmetrical small babies with low birth weight at one year. These infants are
prone to hypertension and death from hemorrhagic stroke in their later life.
-Second trimester undernutrition: As a result of disturbed feto-placental
relationship causes a low ponderal index [weight (g)/length (cms)3 x 100] and a
normal weight at one year. As an adult these babies are prone to hypertension
and non-insulin dependent diabetes mellitus and have high mortality from
coronary artery disease.
-Third trimester undernutrition: On the other hand, results in
asymmetric growth retardation with spared brain growth and reduced weight
at one year. These infants are predisposed to hypertension, low LDL and
fibrinogen and an increased mortality rate associated with coronary heart
disease and thrombotic strokes.
NEED FOR EARLY PREVENTION
All these observations suggest that prevention should start even before
conception and continue during pregnancy. This will require attention to the
risk factors for low birth weight before pregnancy since nutritional
supplements during pregnancy are inadequate. Paediatrics as such is a
preventive medicine and disease in later life also rests on the paediatric nurse.
Preventive child health service should not be viewed as a one-time
measure but is a continuum including primary, secondary and tertiary
preventive efforts. This should lay equal emphasis on –
i. Finding disease incidence/prevalence by screening.
ii. Health promotion and prevention of these disease
iii. Patient management and subsequent follow-up.

Preventive services related to child health can be provided either at the

individual level by health workers, paediatricians and general practitioners or
at the community level integrated with the primary health care approach.

NURSE AS AN INTEGRAL PART:

A nurse can play an integral part in protecting children’s health at all

three levels (primary, secondary and tertiary preventive measures) as:

i. Direct provider of preventive services;

ii. Coordinator of services;
iii. Leader in developing community-based programs.
iv. Advocate for child health.

SOCIAL PAEDIATRICS

Another new concept of child health care is social paediatrics. Social

paediatrics has been defined as “the application of the principles of social
medicine to paediatrics to obtain a more complete understanding of the
problems of children in order to prevent and treat disease and promote their
adequate growth and development, through an organized health structure”. It
is concerned with the delivery of comprehensive and continuous child health
care services and to bring these services within the reach of the total
community.
 It is aimed-

- To meet the health needs of a child. Total health needs should be provided as-

i. Healthy and happy parents.

ii. Balanced and nutritious diet
iii. Clean, healthful house and living environments
iv. Developmental needs like play, recreation, love and affection, safety and
security, recognition and companionship as emotional food.
v. Educational provisions and opportunities.

-To ensure adequate physical, mental and social growth of the child.

MATERNAL HEALTH AND ITS INFLUENCES ON CHILD HEALTH-

Care of children, especially in the age group of 0 to 14 years, is the most
important factor in community. If Parents are assured of good health, they will
have healthy children and be healthy citizens. The child health starts from time
of conception till child becomes independent. For normal healthy baby the
antenatal care starts not only immediately after conceptions, but even before
mother conceives and enters the maternal cycle, so as to prevent disorders like
foetal and neonatal disorders including low birth weight, neonatal asphyxia,
and infection including congenital anomalies. The antenatal care mainly
includes genetic counselling, spacing at birth and limitations of births to one or
two. Delaying the young pregnancy till she is physically and socially mature to
cope with pregnancy and baby care.

Antenatal care-
The primary aim of antenatal care is to achieve healthy mother and baby at the
end of pregnancy.
Antenatal services:
➢ Physical examination-
This includes height, weight, blood pressure, head to toe examination to detect
any abnormality which might interfere with formal labour. Laboratory tests
should include: Blood for haemoglobin. Sugar urine and tests for abnormal
findings e.g., low haemoglobin, high sugar and albumin, etc. Measurement of
fundal height and foetal heart sound to check the growth of child.
➢ Radiological examination-
Ultrasounds can be done as per doctor’s prescription to identify any foetal
abnormalities and the exact condition of the foetus.
➢ Antenatal visits-
Ideally antenatal mother should visit the antenatal care clinic once a month
during first seven months, twice a month during the next two months and
once a week during the last month if everything is normal. At least three visits
during the antenatal care entire pregnancy period, should be aimed at the first
visit to 20 weeks, second visit at 32 weeks, third visit at 36 weeks.
➢ Antenatal advice (health education)
The antenatal advices are the most important aspect of antenatal care. Mother
should be educated about herself and her baby. Mothers must be educated on
the following aspects-
▪ Nutrition- The women during pregnancy must take one extra meal
everyday. The food should contain green leafy vegetables, pulses, fruits
and milk, eggs, cheese, etc.
▪ Reproduction cost energy- A pregnancy in total duration consumes about
60,000 kcal, extra than normal metabolic requirements. Lactation also
requires more than 500 kcal/day. Further, child survival is correlated with
birth survival and birth weight is correlated to the weight gain of the
mother during pregnancy by consuming extra calorie and nutrients. If
mother consumes less iron during pregnancy, leads to less storage, foetus
may receive insufficient iron store. Such baby may show normal
haemoglobin at birth, but may become severely anaemic later, due to lack
of iron in breast milk.
▪ Hygiene- personal hygiene is equally important during pregnancy. Mother
must take care to the cleanliness of the environment in which she lives, to
prevent various infections and diseases.
▪ Regular exercises- Mother is advised to have regular walking exercises. She
can perform light household work, though hard physical labour and lifting
of heavy weight is not advised, which may affect the foetal growth.
▪ Regular bowel movement- Avoid constipation, which may strain the
mother and cause piles. She must have regular bowel movement, by
regular intake of green leafy vegetables, milk, fruit and extra fruit.
Purgatives should be avoided during pregnancy.
▪ Rest and sleep- At least eight hours sleep at night and two hours rest and
relaxation after mid-day meal. If mother has been advised to bed rest, she
must follow the proper instruction to avoid complications, e.g., IUGR,
preterm delivery, bleeding and abortions, etc.
▪ Healthy lifestyle- She must develop healthy lifestyle and avoid smoking or
drinking alcohol, etc. heavy smoking may lead to abnormality among
foetus and placenta due to nicotine effect. Consumption of alcohol may
lead to spontaneous abortion, intrauterine growth retardation, fertility
problems among women and if children are born they may have various
physical and mental problems.
▪ Sexual relationship- Sexual intercourse should be restricted during
pregnancy especially during first and third trimester. If mother has bad
obstetrical history, then avoid sexual intercourse during normal pregnancy.
▪ Drugs- Certain drugs e.g., antibiotics, antipyretics, antitubercle,
corticosteroids taken during pregnancy may, especially first trimester
period, affect the foetal growth and cause foetal malformation.
Streptomycin may cause deafness in the foetus. Corticosteroid may impair
the foetal growth, tetracycline may affect the growth of bones and enamel
formation of teeth. During breastfeeding certain drugs taken may be
excreted in breast milk and may affect the newborn. Hence the drug must
be taken with great caution and under medical supervision.
▪ Radiation- Abdominal X-rays during pregnancy, may lead to congenital
malformation e.g., microcephaly, leukaemia and neoplastic anaemia. X-ray
during pregnancy should be carried out under definite indication,
otherwise it should be avoided as much as possible. Ultrasound radiations
appear to have no effect in pregnancy; this should also be restricted to
once or twice during pregnancy.
▪ Medication- The mother must be given vitamin, supplementation, calcium
and iron tablets regularly after the first trimester; under safe motherhood
programme, every pregnant woman must take 100 iron tablets during her
pregnancy.
▪ Immunization- All antenatal mothers must get two tetanus toxoid
immunization at the interval of at least one month period and if she is
immunized during first pregnancy a year ago, then she can take one dose
of tetanus toxoid at 5 months of pregnancy.
Prevention of health problems:
Though pregnancy is a natural physiological phenomenon, complications
do arise even with best antenatal care. It is therefore important to instruct
the mother to recognize the danger sign and report immediately if:
☻ Bleeding or discharge per vagina
☻ No foetal movement
☻ Swelling of the feet and face
☻ Blurring of vision
☻ Headache
☻ Any other unusual symptoms.
Prevention of health problems during pregnancy-
➢ Toxaemia of pregnancy
Hypertension and presence of albumin in the urine indicate toxaemia of
pregnancy. It is important to diagnose at early stage and treat the
patient.

➢ Anaemia
More than 60% pregnant women in India are anaemic due to low
sociogroup and lack of nutrition, more labour, multiple pregnancy,
neglected female child, etc. Anaemia may lead to premature delivery,
antepartum haemorrhage, postpartum haemorrhage, puerperal sepsis,
etc.

➢ Nutrition deficiency
The nutritional demand is more than the normal requirement during
pregnancy. Hence, intake of milk, vegetables, fruits and vitamin
supplementation, especially vitamins A and D, is important to prevent
nutritional deficiency.

➢ Prevention of infections and communicable diseases

i. STD- Syphilis is a common preventable infection during pregnancy.
Syphilis may lead to spontaneous abortion, stillbirth, perinatal death
and mental retardation in newborn. Venereal disease research
laboratory is done regularly in antenatal clinics to detect any case of
syphilis or gonorrhoea.
 ii. Tetanus- Tetanus can be prevented by immunizing antenatal mother
with tetanus toxoid at 5 months and 6 months, at one month interval
between two doses.
iii. German measles- A mother with German measles infection may lead to
foetal death or malformation like cataract, congenital heart diseases,
deafness, etc. Therefore, it is important to prevent such infection by
getting vaccinated .
iv. Human Immunodeficiency Virus (HIV)- HIV infection may be
transferred from human immunodeficiency virus mother to her foetus,
through placenta or to her newborn during delivery. One-third of
children get HIV through placenta-foetal route. Every pregnant woman
during antenatal visit is advised Enzyme-Linked immunosorbent assay
(ELISA) test to identify human immunodeficiency virus cases, to help
infected women to choose therapeutic abortion or receive appropriate
care.
v. Rhesus (Rh) incompatibility- If the mother is Rh negative and foetus is
Rh positive, it provokes an immune response to her which forms
antibodies which can cross placenta an causes haemolysis. These may
lead to congenital haemolytic anaemia and icterus gravis neonatorum
(newborn pathological jaundice0. If mother is Rh negative and husband
is Rh positive, the blood is examined after 28 to 36 weeks for
antibodies, Rh-anti-immunoglobulin should be given at 28 weeks of
gestation, so that antibody production can be prevented during first
pregnancy. If the child born is Rh positive, then Rh-anti-immunoglobin is
given again within 72 hours of delivery.
vi. Parental genetic screening- For early detection of chromosomal
abnormalities associated with serious birth defects, congenital
anomalies and haemolytic diseases, genetic screening is done for only
recommended cases. In case of any defect therapeutic abortion is
advised.
vii. Mental health- The pregnant woman needs to be prepared mentally to
accept pregnancy as a normal and healthy phenomenon, especially the
primi mothers. Mothers are advised to be mentally relaxed without fear
and anxiety. She must maintain good mental health along with physical
health even after delivery to prevent puerperal psychosis.
Intranatal care
The natal period starts from the onset of labour till the delivery is complete.
It is utmost important to maintain the aseptic technique during delivery
otherwise septicaemia and other complications might result from unskilled and
septic manipulations and tetanus neonatorum from the use of unsterilized
instrument.

Postnatal care:
 Physical examination-
Postnatal examination should be done immediately after delivery, which
includes temperature, pulse, respiration, B.P., head to toe examination
of the mother, inspection for abdomen, cervix for any tear or bleeding,
involution of uterus bladder and bowel movement, breast examination,
etc. The mother is advised for follow up after discharge. Further visits
should be done once a month during first six months and once in 3
months till one year.
 Nutrition-
Mother should eat more than her usual diet including milk, fruits,
vegetables, etc., she needs additional nutrition like vitamins and
minerals. She must take plenty of water so that she can regain her
normal health and breastfeed her infant.
 Hygiene-
Mother and child must maintain proper hygiene to prevent infection and
feel fresh. The mother must take bath with soap and water and put on
clean and loose clothes.
 Rest and exercise-
Postnatal mother should get enough rest and sleep. This helps to
maintain breast milk production. She must avoid straneous work for at
least six weeks and follow abstinence during postnatal period.
 Prevent complications-
A number of complications may arise after delivery. Follow up is
important to identify any danger sign and get appropriate treatment.
 Breast feeding-
Post natal care gives an excellent opportunity for the motherly touch to
the child, physically as well as psychologically by breastfeeding. It
 provides the main source of nourishment in the first year of child’s life.
Timely and adequate breastfeeding is the best guaranteed aid of
ensuring that the newborn is not malnourished, and it also ensures that
the infant is not exposed to unnecessary and preventable infection.
Breast milk is the best food available and is tailor- made to suit the
child’s needs.
Child should be given breastfeed within half an hour of delivery.
Children delivered by caesarean, feeding should be put on the breast
within 4 to 6 hours or as soon as the mother’s condition is stabilized.

ANTENATAL PREVENTIVE PAEDIATRICS-

Fifty years ago, the main purpose of antenatal care was the prevention of
maternal mortality. With the fall in the maternal mortality to about 0.2 per
1000 live births, attention has shifted to the child-
-First to decrease perinatal mortality
-Secondly to prevent perinatal morbidity and
- More recently to the ‘foetus at risk’.
This has given rise to the concept of antenatal paediatrics. Recent technical
developments such as amniocentesis, ultrasonography, foetoscopy and
chorion biopsy have contributed significantly to the diagnosis of congenital
abnormalities and inborn errors of metabolism. This knowledge has led to the
recognition that causation and possible prevention may lie in intrauterine life.
The emphasis has greatly changed in the care of the child with the prevention
of disorders (e.g. low birth weight, foetal disorders and neonatal asphyxia)
assuming greater importance.
Antenatal care should, appropriately, begin even before the mother
conceives and enter the maternity cycle; this care comprising such measures
as-
a. Genetic counselling for prospective parents
b. Limitation and proper spacing of births with intervals of 2-3 years
c. Delaying a young woman’s first pregnancy until she is physically and
socially mature enough to cope with it.
d. Ensuring adequate maternal nutrition
e. Protection of the unborn against intrauterine infections and other
adverse influences.
 In a developing country like India, all this may not be possible, but certainly
some elements, such as improvement of maternal nutrition, family
planning and counselling could go a long way in ensuring maternal and
foetal health.

CONCLUSION:

Prevention counselling is an important aspect of medical management.

It is meant for prevention of diseases and promotion of physical, mental
and social wellbeing of children. It is the responsibility of the health care
providers to raise awareness of issues related to health care among the
community members especially women.

BIBLIOGRAPHY:

1. Piyush Gupta, “essential pediatric nursing”, 1st edition, 2004, A.P.Jain

and Co. 1;11-14.
2. Parul Datta, “pediatric nursing”,1st edition, 2007, Jaypee brothers, New
Delhi. 3; 22 – 24
3. K. Park, “Park’s Textbook Of Preventive And Social Medicine”, 18th
edition, 2005, Banarsidas Bhanot, Jabalpur, 9; 384-386, 391
4. Sunita Patney, “Textbook Of Community Health Nursing”, 1 st edition,
2005, Modern Publishers, New Delhi, 10;108-115.