Mother & Child Care 2003

Mother
and
Child Care
Mother
and
Child Care
Utpal Kant Singh
MD PhD FRCP(Lond) FIAP
Associate Professor
Department of Pediatrics
Patna Medical College, Patna
Rajiniti Prasad
MD
Assistant Professor
Department of Pediatrics
BP Koirala Hospital
Dharan, Nepal
Ranjeet Kumar
MD
Consultant Pediatrician
Sishu Arogya Kendra
Boring Road, Patna
Shivani Suman
Department of Medicine
Cambridge University Hospital
Cambridge, UK
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Mother and Child Care
2003, Utpal Kant Singh, Rajiniti Prasad, Ranjeet Kumar, Shivani Suman
All rights reserved. No part of this publication should be reproduced, stored in a
retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of
the authors and the publisher.
This book has been published in good faith that the material provided by
authors is original. Every effort is made to ensure accuracy of material, but the
publisher, printer and authors will not be held responsible for any inadvertent
error(s). In case of any dispute, all legal matters to be settled under Delhi
jurisdiction only.
First Edition: 2003
ISBN 81-8061-197-3
Typeset at
JPBMP typesetting unit
Printed at
Gopsons Papers Ltd., A-14, Sector 60, Noida
to
Rita Singh
Preface
With growing awareness, care of mother and child has improved
but still a lot is left to be desired. Mother and Child Care is our
endeavor to provide a reference handbook for scientific dealing
with problems of mother and child without neglecting beneficial
traditional beliefs. This book builds on our previous publication
Hand Book of Infant Feeding and also updates practice in care
of pregnant and lactating ladies.
What to do and what not to do during pregnancy and what to
feed and how to feed after delivery is a dilemma shared commonly
by pregnant ladies, nursing mothers, doctors and other health care
personnel. The problem is further compounded by a range of factors
like false social myths at one extreme to modern day demanding
life-style at the other extreme, especially if accompanied by social
ailments like smoking, alcohol consumption and drug-addiction.
This book attempts to provide valuable knowledge about
pregnancy and the necessary care that should be taken during
uncomplicated pregnancy and pregnancies complicated by co-presence of diseases or co-consumption of drugs or substance abuse.
We have attempted to update entire information on breastfeeding,
alternative feeding and weaning. Additionally, the common problems of breastfeeding and bottle feeding has been dealt in a
question-answer format for better understanding. This book also
provides chapters on common neonatal problems like neonatal
jaundice, neonatal skin care, immunization, physical and mental
development, child abuse, nutritional value of food and nutritional
requirements during pregnancy.
It may be mentioned that this book is not meant to be
encyclopedic in its content but is tailored to provide necessary
information regarding mother and child care.
viii
No book can be written without indebtedness to many people.

We acknowledge our deepest gratitude to late FM Morrison and
late Vijayee Singh for them being the leading source of inspiration
in spite of not being bodily present. Our heartfelt thanks goes to
Ms Deepika Padda, IAS for her expert guidance, drawn from her
years of dedicated and selfless service as a Public Administrator.
We are also indebted to Mrs Morrison for her contribution and
blessings. We are thankful to Prof SP Srivastava, Prof V Sharma,
and Prof SA Krishna for their moral support and suggestions. And
of course this book would never have been possible without the
encouragement and support of Rita Singh.
Utpal Kant Singh
Rajiniti Prasad
Ranjeet Kumar
Shivani Suman
Contents
1. Introduction
2. Pregnancy and Baby in Womb
3. Care During Pregnancy
4. Care of Body During Pregnancy
12
5. Epilepsy and Pregnancy
16
6. Diabetes Mellitus and Pregnancy
18
7. Substance Abuse During Pregnancy and Fetus
22
8. HIV/AIDS in Mother and Children
27
9. Pregnancy and Drugs
31
10. Breastfeeding
35
11. Breastfeeding Promotion Network of India
57
12. Not Enough Milk
61
13. Questions and their Answers on Breastfeeding
65
14. Preparation of Babys Feed
68
15. Questions and their Answers on Bottle Feeding
70
16. Jaundice in Newborn
75
17. Neonatal Skin Care and Diaper Dermatitis
79
18. Weaning
84
19. Immunization
90
20. Development : Physical and Mental
92
21. Social, Emotional and Learning Skills
96
22. Help Your Child to be Physically Fit
97
23. Prevent Child Abuse and Neglect
98
24. Vitamins
99
25. Caloric Value of Common Foods
104
26. Nutrition in Pregnancy
107
27. Common Illnesses During First Five Years
111
28. Excessive Crying
147
29. First AID
151
30. Emergencies
155
Index
161
Introduction
C
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A child is the greatest treasure of mankind. His health, well-being,

safety and future is in the hands of his parents from birth until he
is on his own. How the child grows as a person will depend on the
lessons you teach, the values you hold and the way you live. It is a
huge responsibility to any parent to bring up a child. The trip is
wonderful and can be fun and exciting. It can also be tough at times.
Your child should be a perfect human being. You should teach him
kindness and the value of serving others.
Many newborns, if allowed to lie undisturbed on their mothers
abdomen, exhibit a precise sequence of movements that culminate
in their reaching and suckling the nipple. Workers have found that
this breast crawl is an innate mechanism enabling infants to locate
their food source. The close contact of babies with mother may lead
to modulations in arousal and associated CNS-hormonal activity.
The frequent handling of babies may cause stress-induced
activation of pituitary-adrenal system which in turn, leads to
increased plasma cortisol and adrenocorticotropic hormone. The
maternal deprivation has an impact on physiological functions such
as stress hormone response and immunological responsiveness. The
tactile contact of babies seems to increase vagal activity. The increase
in infants vagal activity may lead to an increase in food absorption
hormones such as insulin and may account in part, for enhanced
weight gain.
Breastfeeding hospital initiative has a definite positive impact
on health care practices and breastfeeding. Furthermore, there is
reduction in neonatal and infant mortality rates. Hence mothers
have to be followed up after discharge regarding exclusive breastfeeding practices in family environment.
Pregnancy and
Baby in Womb
C
H
A
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As girls grow up they become aware of their sexuality and the

expectation that they will have children. Pregnancy is one of the
most important events that happen in women. It is the time women
want to learn a great deal about the way a baby develops, about
the birth itself and about caring for the baby. During pregnancy,
women feel a little anxious and apprehensive as they receive lots
of advice and bombardment of new words and medical information.
During pregnancy, babies grow and develop at their own pace
but growth is faster than at any other time of their lives. The baby
usually grows from a tiny egg around the size of a pinhead to an
average of 2.8 kg in weight and 20 inches long in nine months. The
growth not only occurs in the baby but also in the mothers to nourish
the developing baby. The most important changes is the
development of the placenta. The placenta is an organ that serves
as a link between mother and the baby. It begins to grow as soon as
the fertilized egg attaches itself to the wall of the uterus. Oxygen,
nutrients and antibiotics are carried from the placenta to the
developing baby via the umbilical cord. This also carries waste
products away. In addition to physical development in pregnant
women, swings of mood may also occur at anytime because of
hormonal changes occurring in the baby. The following mentioned
changes will help a mother to understand what is happening in
pregnancy.
Babys Development in Womb
First Month
By the end of the first month, the developing baby inside the womb
is about the width of a thumb nail and weighs less than 30 gm. The
Pregnancy and Baby in Womb
correct medical term is Embryo until the end of the second month.
The head, trunk and facial features are beginning to develop as is
the heart.
2nd Month
During the second month, the babys bones begin to form. The
fingers and toes develop along with ears, ankles and wrists. Eyelids
develop but remain sealed. By 7 weeks, the baby will be about 2.5
cm long.
3rd Month
The correct medical term in this month for baby is fetus. The
toes and fingers develop soft nails. The kidneys are also developing.
The baby will also have development of facial features, i.e. tongue
and mouth. Twenty buds appear for future teeth. By the 12th week,
the baby is fully formed and is about 8cm long.
4th Month
By the fourth month, the babys sex may be determined. The baby
will sleep and wake and swallow. The heart beat is strong and fast,
about twice that of an adult. The skin is pink and transparent with
a small amount of hair on the head and eyebrows. The length is
about 18cm.
5th Month
The fifth month is the period of rapid growth. The baby has a regular
asleepawake schedule and will turn from side to side and
sometimes head over heels. The baby may even suck his /her thumb
and will be about 25cm long.
6th Month
The rapid growth of the baby continues. Fine soft hairs, called
lanugo now cover the skin which is red and wrinkled. The length
is about 30cm and baby moves vigorously.
7th Month
The babys growth is very rapid and he/she can open and close
his/her eyes. The baby exercises by stretching and kicking. The
bones are hardening, but the skull remains soft and flexible to aid
birth. The length is about 35 cm.
8th Month
The baby becomes bigger and heavier, therefore does not have the
room to move around much but may kick strongly. Babies in this
month are usually in head down position ready for birth and about
40cm in length.
9th Month
The baby in this month gains about 200-250 gm weight per week.
He is curled up in the fetal position with knees up against nose
and thighs tight against the body. The fine hairs on the body have
disappeared.The baby may then descend into the pelvis getting
ready for birth. Forty weeks is full-term and birth can happen
anytime between 37th and 42nd week of pregnancy.
Developments in Mothers During Pregnancy
1st Month
Though not much differences are seen, the body is changing too.
She may have a tingling sensation and slight discomfort in her
breasts. The period is missed and the nipples may be more
prominent.
2nd Month
The uterus (womb) is now about the size and shape of a pear.
Morning sickness may be experienced. Breasts may be felt larger
and have blue veins visible on them. The uterus, as it gets larger,
pushes the bladder which may result in frequent passage of urine.
Weight gain may only be about 500 gm to 1 kg at this time.
3rd Month
Morning sickness, if it has happened, starts improving. The waist
line, breasts and stomach grow larger and the mother may need to
wear maternity clothes. Nipples may become dark due to extra
pigmentation in the skin. The weight may be increased by 1-2 kg.
Pregnancy and Baby in Womb
4th Month
With the growth of the baby, the size of the uterus increases and
relieves the pressure on the bladder. Thus the frequency of the
passage of urine improves. By the end of this month, the mother
may feel slight movements of the baby, sometimes called
quickening. This feels like a fluttering or slight bubbling. Weight
gain during this month may be about 1-2 kg.
5th Month
The uterus by 5 months almost reaches the mothers tummy button.
The gain in weight varies from 2-3 kg. The heart beat of the baby
can be heard and mothers may start to feel the movement.
6th Month
The uterus will now be above the tummy button. The baby will be
very active and mothers may even feel a heel or elbow as a lump
after pressing on the abdomen. The weight continues to increase.
7th Month
The baby continues to grow, so will the uterus. Breasts also get
increased in size. There may be a feeling of uterine contractions by
mothers called Braxton Hicks contraction. They are quite normal
but worth mentioning to health professionals.
8th Month
The uterus reaches to just under the ribs which may cause a little
discomfort and occasional shortness of breath. Mothers may notice
a slight leakage of clear or yellowish fluid from breasts called
colostrum. Small bulges may appear on the abdomen made by
babys heel or elbow.
9th Month
As the babys head moves into the pelvis (engagement), any breathlessness of the mother will improve but she may again experience
frequent passage of urine because of pressure on the bladder by
the head. However, in some cases, engagement of head does not
happen until labor has started. There may be feelings of a mixture
of fatigue, anxiety and joy. This is all normal but may be discussed
with health professionals.
After the birth of the baby, every mother wants to look at her
baby to make sure he/she is fine and healthy. The baby, should
also be examined by a doctor at this time to detect any health
problems which might need immediate treatment.
Care During Pregnancy
C
H
A
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A pregnant woman may have mixed feelings. She may feel happy
and proud but at the same time, may be anxious and uncertain. In
fact, during pregnancy, feelings may change frequently, from one
day to the next. This mixture of feelings is quite normal, while
adjusting to pregnancy and to the idea of parenthood. It is important
to discuss your feelings openly with ones life partner, health care
professionals, family and friends. After all emotional well-being is
important to good health.
Importance of Antenatal Care
The pregnant women should be educated about good care of health
because caring for herself during pregnancy means good care for
the baby. Once, pregnancy is confirmed, visit your doctor, midwife
or public health nurse once a month, so that blood pressure, weight
and general health can be checked. During the last weeks of
pregnancy, your visits should become more frequent so that the
doctor, midwife or public health nurse can keep a watchful eye on
your unborn baby.
The care, women receive before the baby is born, during pregnancy, is called antenatal care. Women who start antenatal care
early can plan for a comfortable pregnancy and delivery of a healthy
baby. It is important to remember that every pregnancy is different.
Exercise and Work
Some exercise is good during pregnancy, as it will help to keep
body in its best physical condition and contribute to overall muscle
tone and good posture. Everyone has different needs, so contact
the health care professional before engaging in any strenuous
activity or sport.
Tiredness during pregnancy is usual but usually there is no

reason to stop working, although decision depends on the type of
work. Some women continue working throughout most of their
pregnancy, but doctors or public health nurse may advise on what
is best.
Rest and Sleep
It is important that pregnant women should get enough rest,
especially during later months. A rest during the day is good if
possible for 2 hours and should also try to get as much sleep as
possible at night too (at least 8 hours).
Medicines, Alcohol and Tobacco
During pregnancy, especially during the first three months, women
should not take any medication at all, unless it is prescribed by a
doctor. It is also better not to smoke or to drink alcohol during
pregnancy since both of these can have a harmful effect on the health
of the developing fetus.
Tips for Giving up Smoking
Leave a longer stub

Use filter tips
Keep hand busy
Only smoke when sitting down
Do not inhale
Cut out the first cigaret in the day and last one at night
Try chewing gum or sucking peppermints
Sexual Intercourse
As a general rule, there is no reason to stop having sex during
pregnancy, however if there is a history of miscarriage, health care
professionals advice should be followed. Some women find
fluctuation in interest of sex during pregnancy, the middle trimester
is usually the time of most vitality. Women, as long as they feel
comfortable and do not experience any bleeding or cramps whilst
making love, sexual intercourse will not harm your baby. In late
pregnancy, it may be helpful to experiment with different and more
comfortable positions. It is advisable to always discuss this with
health care professional.
Teeth
Some women find that they are more susceptible to dental problems
during pregnancy, so it is important to contact your dentist and as
usual brush your teeth thoroughly at least twice a day. It is also
worth remembering that dental care throughout pregnancy will
safeguard your fetus.
Hair and Skin
During pregnancy, the body goes through some complex hormonal
changes that can affect physical appearance. The skin may darken
and some women may have problems with ones complexion. Skin
and complexion changes usually clear up after delivery without
medications.
The hair may develop a shine and grow faster and thicker. Some
women find their hair becomes excessively oily. After delivery,
some hair losses are expected. This is due to changing hormonal
levels. Do not worry. New hair growth will occur within a few
months.
Clothes
The pregnant woman should choose clothing that is loose,
adjustable and practical. Bras should give your breasts firm support,
without constricting them or flattening the nipples. Do not wear
belts, garters or other elastic garments. Shoes should be low but
not completely flat and should provide support and comfort.
Travel
If possible, try to avoid long trips, especially during the early and
late months of pregnancy. In unavoidable circumstances, avoid
sitting in the same position for long period of time. Women are
advised to move around and stretch occasionally so that you are
more comfortable and prevent stiffness.
If you have to travel by car, sit tall and place your seat belt so
that the lap part is as low as possible on the hips. It is also a good
idea to have a carry cot harness fitted in the back seat so that it is
ready when the baby is born.
Some airlines have restrictions on touring pregnant women and
may require medical approval to travel. So it is advisable to let the
airline know about your pregnancy while booking tickets.
10
Diet in Pregnancy
Diet is important on three counts: the health of the mother herself,
her developing fetus and the alleviation of minor disorders of
pregnancy. Some women will not be conversant with the main food
in terms of protein, fat and carbohydrates, fibre, vitamins and
minerals but can readily understand food groups. Pregnant women
should be explained about regular intake of food which ensures
regular supply of nutrients to the unborn baby.
During pregnancy, a woman should look after herself and eat
regular, well-balanced meals. Make sure you have a portion of meat
or fish, eggs or high protein vegetables (beans or lentils) at lunch
time and dinner. There should be an intake of plenty of fresh fruit
to ensure a good intake of vitamins. Try to drink at least one pint of
milk everyday or alternatively have yogurt or cheese to meet the
calcium requirement.
Weight Control
The pregnant woman should expect to gain about 10-12 kg in weight
during pregnancy. Women should not make any deliberate
attempts to lose weight without first consulting a doctor.
Precautions
Wash thoroughly fruits and vegetables before use
Always wash your hands before and after handling meat,
covered containers in fridge and fruits and vegetables.
Avoid unpasturized milk and its products.
Wash your hand before and after taking meals.
Discomfort in Pregnancy
The amazing number of changes the body goes through during
pregnancy in order to accommodate and develop the baby, is hardly
surprising as women might, at certain times, feel tired or have a
slight discomfort. Some women, of course, feel and look absolutely
marvellous throughout pregnancy and positively glow with good
health but it is unusual to experience some of the following
discomforts.
Backache
Backache during pregnancy is due to changes in your posture and
the relaxation of your ligaments. When picking something up, bend
11
your back properly, i.e. bend knees and crouch down keeping your
back straight instead of bending forwards from waist.
Morning Sickness
In the second month of pregnancy or before, pregnant women may
experience some early morning nausea or vomiting. This usually
disappears by itself, but if persistent, consult your doctor. This can
be prevented by taking small amounts of feed frequently, drinking
plenty of fluids and avoiding heavy meals and fatty foods.
Swelling of Ankles
The added weight of your baby during the second half of pregnancy, increases pressure on veins of legs. To avoid this pressure
try to stay off your feet as much as possible. However, if ankles are
swollen, lie down with legs slightly raised. If your hands and face
get swollen, inform your doctor at once.
Heart Burn
Heart burn is common during later half of pregnancy. This is a
feeling of burning sensation in the stomach, often rising to the
throat. This can be avoided by eating little and often and less spicy
or fatty meals. If the heart burn becomes severe, consult your doctor
for help.
Constipation
Constipation can be avoided by eating a well-balanced diet with
plenty of high fiber diet such as whole grain cereals, whole meal
bread, fruit and vegetables. It is also important to drink plenty of
fluids.
Piles
Piles are varicose veins which occur in the back passage. They can
cause itching or soreness and may bleed. Avoid constipation as
advised above and if bleeding is intractable, consult doctor.
Leg Cramps
The cramp in the backs of thighs and calves may occur during the
last weeks of your pregnancy. They can be relieved by massaging
legs and bending feet upward to stretch the calf muscles.
Care of Body
During Pregnancy
C
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The reduction of the strain during pregnancy is essential which is

best done by some gentle exercises and relaxation. The exercise
and relaxation may be taught in the antenatal period and can be
practised from early pregnancy.
Back
During pregnancy, many women a develop backache because of
hormonal and postural changes. The following exercise will help
to reduce backache.
Lie on your back with knees bent and feet on bed. Draw in your
abdomen and press the back of your waist down into the bed. Hold
this position for 4 seconds but dont hold your breath, then gently
let go. Repeat 5 times.
Lying flat on your back in pregnancy may cause faintness.
Avoid heavy lifting
Use your back correctly to prevent strain while at work and
doing household jobs.
Pelvic Joints
Some women suffer from aching in pelvic joints because of
hormonal changes. Take care of the pelvic joints as follows:
i. Stand evenly on both feet
ii. Sit on both cheeks and do not cross legs.
iii. When rolling over in bed, bend knees, press them together,
tighten your seat and abdominal muscle and then roll.
iv. If you have young children, try not to carry them on one hip.
v. Get into a car by sitting on the seat and then bring in both legs
togetherreverse to get out.
Care of Body During Pregnancy
13
If you have problems with these joints or with your back, consult
your obstetric physiotherapist and your doctor.
Abdominal Muscle
Abdominal muscles are naturally stretched with growth of the baby.
Strong exercises such as sit-ups and double leg lifts will cause
more stretch and should be avoided.
To get up from lying down, always bend your knees, press them
together and roll onto your side before sitting up-reverse to lie
down.
Pelvic Floor Muscles
These are the main support muscles on the floor of the pelvis and
are very important during pregnancy, labor and postnatal months.
Pelvic floor muscle exercises should be practised from pregnancy,
so that it can be done subsequently during labor and after birth.
Close and draw up in the back passages as if you are trying to
keep bowel closed. Then close and draw up in the birth canal. Hold
this contraction for 4 seconds, then relax slowly. Try to make a
habit of doing this 4 times after each time you empty your bladder.
Stopping and starting when emptying the bladder can be used as
an occasional test of these muscles.
General Exercises
It is good for you to continue with most of your usual sports and
activities but some can damage joints which are loosened during
pregnancy, hence avoid taking up new strenuous exercises.
Squatting position is comfortable for some women and useful
during labor, start practising as follows:
Hold something strong, such as heavy furniture, stand with the
feet about half a metre apart and toes turned out, then bend your
knees keeping heels on the floor. Hold this position for a moment
or two and then stand up. Gradually lengthen the time 5-10 minutes
twice a day.
Minor Problems
Cramp
This is due to various biochemical changes during pregnancy and
changing pressure in the abdomen. Wearing very high heeled shoes
14
and sitting cross-legged can make cramp worse. Some women find
that it helps to exercise the feet before going to bed-rotate the feet
ten times in each direction. Try to stretch your legs straight and
pull your toes hard up just before you go to sleep. Another tip is to
raise the foot end of the bed on a couple of bricks.
Swollen Ankles and Varicose Veins
Women with swollen ankles and varicose veins are advised to rest
lying down with legs supported in a raised position, then exercise
your feet up and down and in circles. Avoid standing for long
periods and consider wearing tight leg support.
Numb Fingers
This may be a problem in the morning and is due to extra fluid in
the body, increasing pressure at the wrist. Wearing wrist supports
tightly at night will solve your problem.
If swollen ankles and/or fingers are accompanied by puffy face,
headaches or flashing light, consult your doctor immediately.
Rib Flare
This is due to the growing baby pushing the ribs out of their normal
position. Try to change position frequently and avoid sitting on
low chairs and other positions, which bring the ribs close to pelvis.
Sitting cross-legged (tailor fashion) with hands on head also gives
some relief.
Emotional Changes
The hormonal changes in pregnancy lead to emotional ups and
downs and sometimes forgetfulness. After the birth of the baby
these problems will get better.
Stress, Tension and Relaxation
Some women feel extremely tired, others develop aches and pains
which are not due to specific illness but are related to tension.
Stress and tension cause an increase in blood pressure, heart
rate and rate of breathing which can lead to feelings of panic as
well as overloading the systems of the body. Learning a relaxation
technique and using it regularly has been shown to reduce mildly
Care of Body During Pregnancy
15
increased blood pressure. Women who learn relaxation and use it

during labor, generally cope better with pain and feel more
comfortable. During pregnancy, relaxation will help one to rest
more effectively and can also help one to sleep again. Try to have a
session at least once a day using positions of comfort learned.
Epilepsy and Pregnancy
C
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The prevalence of epilepsy in general population is approximately

1:200 and affects 0.3-0.5 percent of pregnant women. Many women
with epilepsy have pregnancy, therefore care of such women is
very important to improve health of baby and mothers.
Women whose epilepsy is well-controlled, have few problems
during pregnancy. The care of such women should be a combined
approach involving neurologist, obstetrician and midwife, so that
the added stress of multiple hospital appointment can be avoided.
The physiological changes of pregnancy produce hemodilution
and an increased metabolism of anticonvulsant drugs which lead
to a fall in plasma concentration. This results in difficulties in
controlling seizures as pregnancy progresses. Women should be
advised to continue their drug at a dose that maintains therapeutic
levels.
Complications of Anticonvulsant Therapy
a. Anemia
b. Hypocalcemia and vitamin D deficiency
c. Congenital malformations, e.g. orofacial clefts and congenital
heart disease.
Intrapartum and Postnatal Care
Care during labor and delivery is not likely to be any different
from that of other mothers. Seizures are more likely to occur in
conditions such as sleep deprivation, hypoglycemia, anemia, stress
or hyperventilation. So careful observation is very important.
Epilepsy and Pregnancy
17
Effect on Fetus and Neonate

Status epilepticus during pregnancy causes death of approximately
50 percent fetus and 33.3 percent mothers. A single seizure may
cause fetal morbidity from hypoxia or placental abruption.
Anticonvulsants cross the placenta freely and decrease
production of vitamin K producing risk to baby of hemorrhagic
disease. This can be prevented by routine administration of vitamin
K to the mother from 36 weeks of gestation and to the baby shortly
after birth.
Anticonvulsants may have teratogenic effects on the baby and
the baby may suffer from withdrawal symptoms such as tremor,
excitability and convulsions. Anticonvulsants pass into the breast
milk in relatively small quantities. Carbamazepine is the safest drug
during pregnancy.
Breastfeeding is not contraindicated and helps to initiate a good
mother and baby relationship.
Diabetes Mellitus
and Pregnancy
C
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The fetus obtains glucose from the mother via placenta by a process
of facilitated diffusion. From 10th week of pregnancy, there is a
progressive fall in the maternal fasting glucose level but in the third
trimester the mother begins to utilize fat stores which were laid
down during the first two trimesters resulting in rise of blood free
fatty acids and glycerol. The fetoplacental unit alters the mothers
carbohydrate metabolism in order to make glucose readily
available. The placenta manufactures human placental lactogen
(HPL) which produces a resistance to insulin in the maternal tissues.
This results in glucose intolerance which is also contributed by
increased level of estrogen, progesterone and cortisols in last month.
Moreover insulin is produced approximately two or three times of
normal. The extra demands on pancreatic beta cells can precipitate
glucose intolerance or overt diabetes in women whose capacity for
producing insulin was only just adequate prior to pregnancy. If a
mother was already diabetic before pregnancy, her insulin needs
may be increased.
Gestational Diabetes
Some women are at special risk of developing diabetes during
pregnancy and may be identified when history reveals one or more
of the following:
i. Diabetes in a first degree relative.
ii. Recurrent abortion
iii. Unexplained stillbirth
iv. Congenital abnormality
v. Baby weight more than 97th centile for gestational age
vi. Previous gestational diabetes or impaired glucose intolerance
vii. Persistent glycosuria
viii. Weight gain more than 20 percent of normal.
Diabetes Mellitus and Pregnancy
19
The progressive increase in insulin demand during pregnancy

can make latent diabetes appear which may resolve after the
delivery.
Detection of Diabetes in Pregnancy
Women considered at risk of gestational diabetes should undergo
glucose tolerance test and frequent urinary tests.
According to WHO, glucose tolerance test would be considered
abnormal if, between 28 and 34 weeks of pregnancy, glucose levels
in venous sample exceeds the following:
Fasting blood sugar = 7.9 mmol/L
Blood sugar 2 hrs after meal = 11 mmol/L
Effect of Diabetes on Pregnancy
When diabetes is well-controlled, its effect on pregnancy may be
minimal. If the control is inadequate, the outcome may be poor in
terms of maternal complications and fetal abnormalities.
Mother
The uncontrolled diabetes in pregnancy may cause following
problems in mother
i. Increased risk of spontaneous abortion
ii. Increased risk of infections, i.e. UTI, Candida vaginitis
iii. Increased risk of pre-eclampsia
iv. Polyhydramnios
v. Preterm labor
vi. Prolonged labor and obstructed labor.
Baby
The effect of uncontrolled diabetes on the fetus is partially due to
disturbed maternal metabolism. Fetal hyperglycemia during pregnancy is thought to be responsible for large baby and congenital
malformation.
i. Increased risk of congenital malformations of cardiac, skeletal
and gastrointestinal tract.
ii. Large baby leading to obstructed labor
iii. Increased risk of birth asphyxia
iv. Intrauterine death
20
v. Increased risk of injuries to baby, and

vi. Respiratory distress
No particular congenital abnormality is typical but rare
combination of sacral agenesis and neurological defects is most
often seen in babies of diabetic mother.
Pre-pregnancy Care of the Known Diabetic
The diabetic woman should consult her doctor for preconception
care and advice, because complications can be reduced by strict
control of diabetes. She must be examined for the presence of renal,
cardiovascular or retinal changes before becoming pregnant.
The woman should continue using some form of contraception
(Barrier) while improving her diabetes. Following advice should
also be given:
a. Stop smoking
b. Weight control
c. Regular exercises
d. Early antenatal care.
Antenatal Care
A diabetic woman should be advised for registration in a hospital
with a neonatal intensive care unit. She should be seen at a combined antenatal and diabetic clinic. Antenatal visits should be
fortnightly until 28 weeks of gestation and then weekly until term
to maintain good diabetic control. The following should be advised
in addition.
1. Attention to good hygiene
2. Strict control of diabetes
3. Adherence to diets prescribed by dietician
4. Detection of fetal abnormalities as early as possible by
ultrasonography.
5. Serum alpha-fetoprotein to detect neural tube defect in baby.
6. Regular check of maternal weight
7. Early detection of polyhydramnios
8. Light exercises
9. Insulin if mother is on oral antidiabetic drugs previously.
Diabetes Mellitus and Pregnancy
21
Postnatal Care
Mother
The carbohydrate metabolism returns to normal very quickly after
delivery of the placenta and insulin requirements will fall rapidly.
The woman can resume her pre-pregnancy regimen.
A diabetic mother who is breastfeeding may need to increase
her carbohydrate intake by 50 gm a day and may need insulin
adjustment. Although small amounts of insulin may enter breast
milk, these are destroyed in the babys stomach. Women are advised
to change their pads frequently in order to keep wound clean and
dry.
Baby
Birth asphyxia is common in both macrosomic and growth retarded
babies. Babies are usually prone to injuries. Hence babies should
be examined carefully for injuries and congenital malformations
by doctor.
After birth, the babies are prone to hypoglycemia because of
continuing increased secretion of insulin by -cells of pancreas. Thus
all babies should be fed as early as possible and observed for
hypoglycemia during first 48 hours of birth.
Substance Abuse During

Pregnancy and Fetus
C
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Substance abuse during pregnancy has been recognized for many

decades. Psychotropic substances, both legal (alcohol, cigarets) and
illegal (heroin, amphetamine, cocaine) during pregnancy may cause
adverse impact on the health of child and fetus.
Despite awareness of pregnant mothers regarding adverse
effects on fetus, common reasons for substance abuse are anxiety,
depression, peer group pressure, high euphoria, energy addiction
and need. There are enhanced risks in fetus such as malformations,
abortion, IUGR, prematurity, withdrawal symptoms, neurologic
sequelae, SIDS and foster care, after substance abuse during
pregnancy.
General Behavior Characteristics of Substance Abuse
Abrupt changes in work, quality of work, grades, discipline and
workout
Unusual flare-ups or outbreaks of temper
Withdrawal from responsibility
General changes in overall attitude
Deterioration of physical appearance
Furtive behaviors regarding actions and possessions
Continued wearing of long sleeved garments (to hide injection
marks)
Association with known users of drugging substances
Unusual borrowing of money from parents or friends
Stealing small items from home or employer
Attempts to appear inconspicuous in manner and appearance
Move places, without cause.
Substance Abuse During Pregnancy and Fetus
23
Opiate Abuse and Pregnancy

Opiates have been used as analgesics for centuries and remain the
most effective analgesics available. Opiates of clinical interest
include morphine, heroin, methadone, pethidine and codeine. The
prevalence of opiate abuse during pregnancy varies from 1 percent
to 21 percent and is more common in women of lower socioeconomic group.
Maternal Impact of Opiate Abuse
1. Poor general health with multiple medical problems and
increased risk for multiple infectious complications such as
cellulitis, thrombophlebitis, hepatitis, endocarditis, syphilis,
gonorrhea and AIDS.
2. Less likely to receive prenatal care
3. Malnutrition
4. Iron deficiency anemia
5. Other nutritional deficiency
6. Higher incidence of obstetric complications
a. Spontaneous abortion
b. Premature delivery and labor
c. Abruptio placentae
d. Increased risk of chorioamnionitis
e. Increased risk of cesarean delivery
f. Fetal distress.
Fetal Impact of Opiate Abuse
The fetus is always at risk of the following:
1. Prematurity
2. Intrauterine deaths
3. Meconium aspiration syndrome
4. Birth asphyxia
5. Low birth weight
6. Intrauterine growth retardation
7. Sudden infant death syndrome
8. Neonatal withdrawal syndrome.
Clinical Manifestations of Neonatal
Opiate Withdrawal Syndrome
CNS: Irritability, excessive cry, jitteriness, hyperactive reflexes,
hypertonia, sleep disturbances and seizures.
24
Autonomic dysfunction Excessive sweating, mottling, hyperthermia

and hypertension.
Respiratory system Tachypnea, nasal stuffiness.
Gastrointestinal and feeding disturbances Diarrhea, excessive suckling
and hyperphagia.
Opiate Abuse Can Cost You Your Fetus
Cocaine Abuse and Pregnancy
Cocaine is highly psychoactive stimulant with a long history of
abuse. It inhibits postsynaptic reuptake of norepinephrine, dopamine and serotonin neurotransmitters by sympathetic nerve
terminals and causes hypertension, vasoconstriction and tachycardia. The prevalence of abuse varies from 1 to 13 percent and is
more in adolescent age group particularly females.
Cocaine use results in a sense of well-being, increased energy,
increased sexual excitement and intense euphoria. In mothers, it
has been associated with cerebral hemorrhage, cardiac arrest,
cardiac arrhythmias, myocardial infractions, intestinal ischemia and
seizures. Chronic use ultimately results in neurotransmitter
depletion characterized by lethargy, depression, anxiety, insomnia,
hyperphagia and cocaine craving.
Clinical impacts on pregnant mother and infant with cocaine
abuse.
a. Pregnant women
Spontaneous abortion
Abruptio placentae
Stillbirths
Premature delivery
Anemia
Malnutrition
b. Fetus
Low birth weight

IUGR, small head size
congenital syphilis
HIV infection
Congenital malformation involving skull,
CNS, Eyes and CVS
Neurodevelopmental delay
Prosencephaly and seizures
Substance Abuse During Pregnancy and Fetus
25
Management
1. Antenatal urine toxicological analysis
2. Screening for syphilis and HIV
3. Counseling of pregnant mothers about
a. Screening of STDs
b. Monitoring of maternal and fetal well-being.
c. Drug counseling
d. Support and referral for rehabilitation
e. Emphasis on social service needs
4. Postpartum education and parenting skills
5. Need for frequent obstetric and neonatal care.
Alcoholism and Pregnancy
Alcoholism in women is common in affluent families and lower
socioeconomic groups. Women who are chronic alcoholics, may
also have a greater risk for abruptio placentae, spontaneous
abortion and stillbirths. The adverse effects of alcohol on fetus are
related to the gestational age at which exposure occurs, the amount
of consumption, binge drinking and individual susceptibility. There
is no documented safe level of alcohol ingestion, thus women are
advised to abstain from alcohol during pregnancy.
The exposure of fetus to alcohol can result in devastating effects,
i.e. fetal alcohol syndrome (FAS). The incidence of FAS is 0.5 to 3.0
per thousand live births and is considered as leading cause of
mental retardation. Women who consume greater than 2 ounces
of absolute alcohol per day, FAS occurs in about 30 to 40 percent of
the offspring.
Clinical Manifestations of Fetal Alcohol Syndrome
1.
2.
3.
4.
Prenatal and postnatal growth deficiency

Microcephaly
Mental retardation
Abnormal facies : short palpebral fissure, broad flat nasal bridge,
short upturned nose, long upper lip without distinct philtrum
and flat maxilla.
5. Eye abnormalities: microphthalmia, strabismus, ptosis
6. Jitteriness and poor feeding
7. Congenital heart disease, i.e. VSD.
26
Effects in Childhood Period

1.
2.
3.
4.
5.
Speech and language problems

Behavioral problems
Attention deficit disorder
Learning disabilities
Mental retardation.
Smoking and Pregnancy

Cigarets are most often used during pregnancy and has been
associated with increased risk of spontaneous abortion, stillbirths,
fetal growth retardation, prematurity and SIDS. The degree of
intrauterine growth retardation is related to the number of cigarets
smoked per day.
Cigarets contain a number of potentially toxic substances which
induce hypoxia in fetus. Fetal hypoxia is either from carbon
monoxide production or from nicotine induced vasospasm.
Effects on Fetus
1.
2.
3.
4.
5.
Intrauterine growth retardation

SIDS
Recurrent otitis media
Asthma
Neurobehavioral changes
Mothers who smoke during pregnancy, commonly smoke their fetus.
Caffeine and Pregnancy

The prevalence of caffeine exposure during pregnancy is approximately 75 percent and is usually consumed as coffee, tea, colas
and chocolate. Caffeine intake more than 300 mg per day in
pregnancy may pose her fetus at increased risk of intrauterine
growth retardation and spontaneous abortion.
Women are advised to limit caffeine intake to less than 100 mg
per day both when pregnant and anticipating pregnancy.
HIV/AIDS in Mother
and Children
C
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The epidemic of HIV, worldwide has a major impact on maternal

and child health. Approximately 12 million women and 1.1 million
children have been infected with HIV. Gains in child survival
attributed to widespread children immunization and oral
rehydration programs have been severely eroded by increase in
mortality from HIV infection in the 1990s.
HIV is a retrovirus that affects mainly helper T-lymphocytes,
monocytes and macrophages. In general, cells are affected after
binding of the glycosylated envelope protein of HIV gp 120 to both
CD4 receptor protein and a chemokine receptor which are found
on the surface of the target cells. The function and number of CD4
lymphocytes are diminished by infection, with profound effects
on both humoral and cell mediated immunity. Without treatment,
HIV infection causes generalized immune incompetence and
progression to AIDS.
Transmission of HIV from Mother to Baby
The transmission of HIV from infected pregnant women to her fetus
occurs during pregnancy (in utero) or labor and delivery
(Intrapartum) and through breastfeeding (postpartum).
Period
Percentage (%) of risk

of HIV infection in
babies
1. In utero (pregnancy)
2. Intrapartum (labor and delivery)
3. Postpartum (Breastfeeding)
5-6
13-18
12-14
28
Factors Influencing Mother-infant Transmission

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Maternal viral load

Premature delivery
Breastfeeding
Frequent abortion
Prolonged rupture of membrane
Vaginal delivery
Multigravida
Frequent unprotected sexual intercourse with multiple
partners during pregnancy.
Maternal drug abuse during pregnancy
Maternal anemia and low maternal vitamin A levels
Maternal zidovudine therapy
Invasive procedures during pregnancy such as chorionic villus
biopsy and amniocentesis
Low CD4 cell count.
Breastfeeding and HIV Transmission

Infants born to mothers with HIV infection who escape infection
during gestation and delivery may still become infected through
breastfeeding. The rate of infants not infected at birth but infected
through breastfeeding is estimated at 12 to 14 percent. HIV is
commonly contained in the breast milk of HIV-infected women.
The mechanism of transmission through breastfeeding is most likely
the frequent and prolonged exposure of infants oral and
gastrointestinal tract to breast milk.
In developing world including India, where the prevalence of
HIV infection among childbearing women is high, the use of breast
milk substitutes (Powder milk, animal milk) could place the infants
at increased risk for death from diarrheal and respiratory infections
related to unsafe water supply and loss of immunologic protection
afforded by breast milk. In addition, in some areas, the act of not
breastfeeding may place a substantial social stigma on these
mothers which may jeopardize survival outcomes for woman and
their offspring because of violence and abandonment.
Prevention of Perinatal HIV Transmission
The prevention of HIV transmission should be focused on four areas
a. Reducing viral load of mother
b. Reducing exposure to HIV during pregnancy
HIV/AIDS in Mother and Children 29

c. Prevention of infection during or after exposure, and
d. Reduction of exposure to HIV during breastfeeding.
Reduction of Viral Load in Mother
The higher the viral load, higher the risk of HIV transmission to
fetus. Antiretroviral therapy, i.e. Zidovudine during pregnancy is
effective in reducing the risk of transmission.
Reduction of Exposure of Fetus at Delivery
Infants are intensively exposed to HIV infected blood and cervicovaginal secretions of their mothers during labor. The minimal
contact of baby with blood and secretions of mother may reduce
transmission risk. Elective cesarean section has been shown to
significantly reduce transmission. A short course antenatal
zidovudine started at 36 weeks has shown to reduce transmission
risk by 50 percent. Vaginal disinfection and cleaning of neonates
did not demonstrate an overall reduction in risk for HIV
transmission.
Reduction of Risk for Infection if Exposed
Infants who have been exposed to HIV during labor and delivery,
antiretroviral therapy, given during or following exposure probably
blocks infection in some cases. Zidovudine should be started within
12 hours after delivery and continued for 6 weeks. The dose of
zidovudine is 2 mg/kg orally four times daily.
Reduction of Postpartum Exposure to HIV
Noninfected infants born to HIV infected mothers are still at risk
for infection if breast-fed by their mothers. Miotti et al suggested a
higher risk for transmission in first 6 months of life compared with
second year of life.
Prevention of HIV Infection in Mother
The only 100 percent effective method of avoiding sexual transmission of HIV infection is abstinence or limiting sexual contact to
a mutually monogamous partner who is not HIV infected.
However, condoms used consistently and correctly are highly
effective in preventing transmission. Prompt treatment of other
30
sexually transmitted diseases also reduces the risk of sexual

transmission. Vertical transmission can be prevented by giving antiretroviral therapy to the mother. Routine HIV testing with informed
consent to all pregnant women should be done. Women found to
be infected should be counseled regarding all HIV related pregnancy care issues, including risks and benefits of anti-retroviral
therapy. All medical equipments that can penetrate the skin should
be sterile. Infected blood and secretions should be handled
according to CDC recommendations.
Immunization in HIV Infected Infant
The inactivated (killed) or cell component vaccine such as DPT, H.
influenzae type b vaccine, hepatitis-b vaccine and influenza vaccines
should be given as per recommended times. OPV should not be
given because of the possibility of vaccine associated poliomyelitis
in infants. Inactivated polio vaccine is recommended both for the
patient and for healthy children in the household. MMR vaccine
and measles vaccine should be given as per schedule because of
high risk of measles in HIV infected infants.
Public Health Issues
The infant or child who is well enough to attend day care or school
should be treated no differently from other children. Routine good
hygiene should be practised. The school health care provider and
teacher should be aware of the diagnosis but there is no legal
requirement that any individual at the school or day care center be
informed. Saliva, tear, urine and stool are not contagious if there is
no gross blood in these fluids. A barrier protection should be used
when possible contact with blood or bloody body fluids may occur.
Razors and tooth brushes should not be shared. Blood soiled
clothings may be washed routinely with hot water and detergent.
The contaminated surfaces may be disinfected easily with a variety
of agents such as bleaching powder, lysol and isopropyl alcohol.
Pregnancy and Drugs
C
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T
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In the era of environmental toxins and drug exposure, both

prescribed and illicit, the maternal duty to nurture the fetus becomes
even more difficult. Most maternal exposures, ingestions and
diseases influence the fetus, sometimes profoundly. A drug which
is apparently safe and well-tolerated by the mother, may be harmful
and damaging to the fetus. No drug is entirely safe for the fetus.
The exact mechanism of placental transport is unknown but
postulated methods are simple physical diffusion, active transport
and pinocytosis.
The fetal hazards and disadvantages far outweigh the possible
benefits of maternal medications. Approximately one-third of
pregnancies are known to end in abortion and in vast majority, the
precise cause remains unknown. The first trimester is most
vulnerable to teratogenic effects of drug because organogenesis is
essentially complete around 8-10 weeks postconception except
brain and genital system which continue to differentiate throughout
the pregnancy. The major cause of congenital malformations
remains unknown but is thought to be due to alterations in the
fetal environment during period of embryogenesis. Chemotherapeutic agents such as quinine, phenytoin, thalidomides, oral
hypoglycemic agents, tetracycline, anti-metabolites, cytotoxic
drugs, etc. have shown to be teratogenic in different species of
experimental animals and even human beings. The following table
will be a useful guide for drug therapy during pregnancy.
Every married women in reproductive age group is potentially
capable of becoming pregnant and may expose her fetus to an
environmental hazard before she becomes aware of the fact that
she has conceived. Therefore, the radiological studies should be
restricted to the second week of postmenstrual period and no pelvic
radiograph should be taken during first trimester of pregnancy.
32
S/N

Maternal therapy
Effects on fetus
Recommended safe drugs
1. Antimetabolites
and cytotoxic drugs
Fetal death, cong.

Azathioprine and
malformations,
cyclosporine
cranial dysostosis,
micrognathia microtia,
growth retardation,
chromosomal anomalies
and bone marrow
suppression.
2. Antibacterial
IUGR,
Penicillin and aminoagents
methemoglobinemia,
penicillin
hemolytic anemia,
Erythromycin
teeth discoloration
Cephalosporins
(Tetracycline)
[Antibiotics are safely tolerated by fetus and would safeguard fetal well-being in
seriously infected mother]
3. Anticonvulsants
a. Phenobarbitone
Bleeding in neonates
Carbamazepine
b. Phenytoin sodium Hydantoin syndrome,
Phenobarbitone
Cleft lip and palate, cong.
heart disease, hypoplasia
or absence of nails, microcephaly, IUGR, mental
retardation. Broad and
depressed nasal bridge
c. Valproic acid
Neural tube defects
4. Antihypertensive
a. Reserpine
Nasal stuffiness, snuffles
Hydralazine
respiratory difficulty and
Alpha-methyldopa
lethargy
Calcium-methyldopa
b. B-blocker
IUGR, bradycardia
Prematurity,
hypoglycemia
Hyperbilirubinemia
(Labetalol: Enhances lung maturity and reduces incidence of hyaline membrane
disease)
5. Antimalarial
a. Quinine
Abortion, deafness,
Chloroquine
thrombocytopenia
and retinal pigmentation
b. Primaquine
Hemolytic anemia
6. Antithyroid
Carbimazole
Fetal goiter and cretinism
Propylthiouracil
I131
Damaged fetal thyroid,
hypothyroidism and brain
damage
Contd...
Pregnancy and Drugs
33
Contd...
S/N
Maternal therapy
7. Anti-diabetic
Tolbutamide
Sulfonyl ureas
8. Corticosteroids
9. Diuretics
10. Sedatives
11. Anti-tuberculous
a. R-cin
INH
b. Ethambutol
c. Streptomycin
d Ethionamide
e. Pyrazinamide
12. Anticoagulants
a. Dicoumerol
b. Warfarin
Effects on fetus
Teratogenic
Hypoglycemia
Prematurity
Cleft palate
Perinatal mortality
Adrenal crisis
Insulin
Electrolyte disturbances
Thrombocytopenia
Liver damage
Use should be restricted

in pregnant women
with pulmonary
edema, acute renal
failure and acute cardiac
failure
Congenital defects,
difficulty in initiating
breathing, carebral
depression, hypothermia,
inactivity, and poor feeding
None are safe, if

necessary diazepam/
midazolam may be used
Fetal hepatotoxicity
Bleeding diathesis
Ideal regimen
INH + R-cin +
Ethambutol
Minor congenital
malformations
(supernumerary nipples,
congenital dislocation
of hip, hydrocele,
strawberry marks
skin tag)
Deafness and vestibular
dysfunction
Abortion and congenital
malformation
Teratogenic
Fetal death
Severe bleeding
Hypoplasia of nasal bones,
Stripped calcification of
epiphysis
Prednisolone
Heparin
Contd...
34
Contd...
S/N
Maternal therapy
13. Analgesics
a. Salicylates
b. Morphine and
Pethidine
14. Anesthetic agent
a. General
anesthesia
b. Local
anesthesia:
for paracervical
block
c. Spinal
anesthesia
14a.Anti-emetics
Metoclopramide
Domperidone
15. Vitamins
a. Vitamin-K
b. Vitamin-D
c. Vitamin-B6
d. Vitamin-A
e. Vitamin-E
16. Thalidomide
17. Radiotherapy and

Irradiation
Effects on fetus
Bleeding diathesis
Bilirubin encephalopathy
Methemoglobinemia
Platelet dysfunction
Respiratory depression
Paracetamol
Respiratory dipression
and difficulty in initiating
breathing
Accidental injection to fetus
may cause apnea, hypotonia,
bradycardia and intractable
seizures
Fetal hypoxia
Increasing risk of jaundice
(Bupivacaine)
Teratogenic
Nitrous oxide
Nalorphine
Spinal anesthesia is
recommended for
cesarean section
Pyridoxine
Hemolysis, hepatotoxicity
Vitamin B-complex
Severe neonatal jaundice
Infantile hypercalcemia
Supravalvular aortic stenosis
Inhibition of lactation
Renal malformation, neural
tube defects, hydrocephalus,
increasing risk of abortions
Teratogenic
Phocomelia, hemangioma,
microtia, duodenal and anal
atresia congenital cardiac
defects and mental
retardation
Chromosomal abberation
Leukemia
Use Minimum Drugs during Pregnancy
Breastfeeding
C
H
A
P
T
E
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10
If ever I get a chance, I should love to be reborn just

to have the ecstasy of being re-fed by the kindly mother
Oscar Wide
The term breastfeeding is a misnomer perhaps, as feeding is merely
one of the many beneficial effects of breastfeeding. Mothers milk is
like nectar, the name given by Homer to beverages offered by God
giving life and beauty. Human milk is the most appropriate of all
available milks for human infants as it is specific to his or her needs.
Breast milk provides complete nutrition to infants during the first
six months of life. The World Health Organization, the UNICEF,
The International Organization of Pediatricians, have recommended
mothers milk as the best food for the newborn. Breastfeeding not
only reduces the mortality but also the morbidity in infants and in
later life. Choosing how to feed your new baby is a very important
decision as it has an effect on both your babys health and your own.
Areas of Concern in Breastfeeding
The lack of confidence, widespread ignorance and misconceptions
frequently result in improper management of infant feeding, which
directly or indirectly contributes substantially to infectious illness,
malnutrition and mortality in infants. The major areas of concern
include:
1. Widespread use of prelacteal feed such as boiled water, water
with jaggery, honey, sugar or herbs.
2. Discarding or minimum feeding of colostrum and delayed
initiation of breastfeeding by nearly 80 percent of mothers.
3. Non-exclusive breastfeeding by 85-90 percent of mothers and
36
unnecessary utilization of commercial infant milk food and/or

animal milk.
4. Early termination of breastfeeding and delayed introduction of
semisolids.
5. Mothers worry that they will not produce enough milk or that
their milk will not be sufficiently nourishing.
6. Lack of antenatal education and advice regarding retracted and
cracked nipple.
Advantages of Breastfeeding
For Baby
1. Breast milk is natural, always fresh, convenient, inexpensive,
easily digestible and optimum for babys growth and development.
2. Breast milk is best suited for the requirements of infant. It is
proven scientific fact that all commercial infant milk, food and
animal milk are inferior to breast milk.
3. Less solute load to kidneyBreast milk has low protein, less
minerals and high concentration of water as compared to other
milks. Hence renal tissues of newborn will have lower solute
load.
4. Enhanced bioavailability of calciumThere is increased
absorption of calcium due to active lipase in the breast milk,
which provides free fatty acids and thus there is absence of
tetany due to functional hypoparathyroidism in the breast-fed
newborn.
5. Sterile and readymadeBreast milk is sterile and ready for
use. There is no risk of external contamination as the milk passes
directly from the mother to the infant. Therefore infections like
gastroenteritis, dysentery and vomiting are unlikely in breastfed infants.
6. Protection against infectionsbreastfeeding protects against
several infections such as diarrhea and respiratory infections.
An exclusively breast-fed infant is about 14 times less likely to
die from diarrhea and 3-4 times less likely to die from other
infections, than a non-breast-fed infant.
Breast milk contains several factors which are protective
like immunoglobulins, iron binding protein lactoferrin, lysozymes, interferon, bifidus factor, phagocytic macrophages and
live lymphocytes. Lactoferrin and bifidus factor inhibit the
Breastfeeding
6.
7.
8.
9.
10.
11.
12.
13.
14.
37
growth of E. coli. The presence of para-aminobenzoic acid in

the breast milk provides protection against malaria. Apart from
these, antibodies against poliovirus, shigella, staphylococcus,
streptococcus, salmonella and E. coli are present in breast milk.
Eczema and allergic diseasesIntestinal mucosa of the infant
during the first 6-8 weeks is immature and is easily disrupted
by infections and toxins. So there is greater risk of absorption of
macromolecules of proteins by the intestinal mucosa. Normally
higher concentration of secretory IgA in the breast milk inhibits
absorption of macromolecules of protein. In contrast, betalactoglobulin of animal milk is antigenic and may sensitize
some babies resulting in increased incidence of eczema and
perhaps asthma also. This is more likely in those children who
have a strong family history of allergic diseases. Infants, who
are exclusively breast-fed upto the age of six months, are less
likely to suffer from these diseases.
Less smelly nappies of baby.
Less risk of diabetes mellitus in later age.
Better mouth formation and straighter teeth.
Less risk of lymphomas than those fed on formula milk.
Better mental development : Breast milk contains high amount
of lactose which provide substrate galactose. Galactose is
essential in newborn for proper neurological development as it
is one of the most important constituent of various complex
lipids of neural tissues.
There is considerable evidence to show that free fatty acid
present in human milk offers some protection to the baby against
atherosclerotic disease, obesity and hypertension in later life.
Emotional satisfaction: Breastfeeding provides emotional
satisfaction both to the mother and the baby promoting close
physical and emotional bonds between the mother and the baby.
This leads to better parent-child adjustment and social
adjustment and fewer behavioral disorders in children.
Breastfeeding has been shown to be associated with higher
cognitive ability in adolescence:
For Mother
1. Psychological satisfaction: Nursing the baby gives the mother
psychological satisfaction and a sense of fulfillment.
2. Breastfeeding is more convenient for the mothers. It saves her
hours of valuable time as there is no bottle to clean and sterilize,
38
3.
4.
5.
6.
7.

no formulas to mix and cook several times the day and night.
Travelling is much easier as there are no bottles or tins of milk
to carry. Even at night, it is the easiest way to feed the baby.
Rapid involution of uterus: Breastfeeding ensures earlier
termination of postpartum bleeding and better involution of
postpartum uterus.
Spacing of pregnancy : The traditional belief that lactation is a
means of contraception, is well-supported by medical research.
Lactational amenorrhea partly helps in spacing of pregnancy
and in conservation of maternal iron. Though the contraceptive
effect of lactation is not full proof, a small but definite impact on
population control cannot be denied.
Mothers, who breast-feed their babies, enjoy a very low incidence
of cancers of breast and ovary.
Faster return to prepregnancy figures: There is no truth in the
widely held misbelief by the mothers that breastfeeding spoils
their figure. The changes that do occur in the body result from
over-eating, inactivity or pregnancy itself. Whether or not one
breast-feeds, the final changes in breast tissues are the same. A
good supporting brassiere would help to maintain the full
contours of the breast. If done properly, breastfeeding infact
improves and shapes the young mothers figure. It helps her to
slim since it enables the uterus to return to normal size and it
drains away extra fat that accumulates during pregnancy.
It has been shown in various studies that bones are stronger in
later life in mothers who had breast-fed their babies.
Why Breast Milk is Most Appropriate for Your Baby ?

1.
2.
3.
4.
5.
6.
Contain proportionate amount of lactose, protein and fat

Decreased solute load as compared to other milk
Easily digestible
Better absorption of calcium
Provides all vitamins and minerals
Contains antibodies to protect your baby from infection.
Breastfeeding will benefit you and your baby for as long as you
both wish to continue feeding. It is best to breast-feed at least for 6
months.
Your breast milk is perfect for your baby and adapts to meet
your babys changing needs.
Breastfeeding
39
How to Breast-feed?
This is a new skill. So, the mother should learn from attending
midwife, nurse or doctor. The following hints will give some basic
ideas.
A. First find a comfortable position, either sitting upright, wellsupported or lying down.
B. Then turn your baby towards yourself with head and shoulders
opposite your breast and the nose opposite the nipple. Support
the baby with a hand across the shoulders, not behind the head.
C. Now brush your babys lips against your nipple to get her to
open her mouth really wide, then draw the baby to the breast
quickly. If the baby is correctly positioned, there will be more of
your areola (the brown skin around your nipple) showing above
the top lip than below the bottom lip.
Start each feed on alternate sides. Let your baby decide when he
or she has finished the first breast before switching to the second.
Sometimes babies only need one breast at a feed.
Many babies develop a pattern of feeding but you need not let the
baby wait for a feed, nor restrict the length of the feed.
A Good Start
No matter how mothers choose to feed their baby, spending some
time quietly holding them in skin-to-skin contact straight after the
birth is very important because it
i. helps to calm your baby
ii. keeps him/her warm
iii. steadies your babys breathing
iv. gives mothers time to bond with baby
v. helps get breastfeeding off to a good start.
If mother and baby are both well, mother should hold her baby
straight away. Ask midwife or nurse to dry the baby first. A blanket
over both mother and baby will help to keep baby warm.
If mothers have a cesarean delivery or have to be separated from
their babies for a while after delivery, skin contact should be made
as soon as possible.
Guidelines for Successful Breastfeeding
1. Education and motivation of the pregnant mothers about
40
breastfeeding.
2. Treatment of cracked or retracted nipple before delivery.
3. Practise exclusive breastfeeding. First feed should be mothers
milk only. Dont give any prelacteal feeds such as honey, ghee,
water, glucose, etc.
4. Explanation regarding correct position of the baby against the
breast.
5. On demand feeding schedule.
6. Nutritious diet to mothers.
Feeding Schedule
The feeding schedule should not be too rigid. The requirements of
the baby are minimal during the first few days of life, so the small
amount of milk secreted in the initial few days are sufficient for the
baby. Babies are sleepy in the initial few days, so require arousal by
gentle tickling. There should be semidemand schedule. Baby should
be fed on demand and when he does not demand for more than
three hours, he should be fed. At least 8-12 feeds per day should be
given and there should be at least two night feeds in early life.
A baby can digest a full feed of breast milk in about an hour and
half to two hours (half the time taken for a formula fed babies to
digest full feed). Breastfeeding on demand thus means frequent
feeding; but this will not deplete milk resources. Various studies
have shown that mothers who breast-feed their babies on demand
produce more milk than those who feed their babies at regular but
less frequent intervals.
Several studies have shown that babies, breast-fed on demand
get an average of nearly ten feeds a day, compared to an average of
just over seven feeds in babies fed every 3 to 4 hours. The more
frequent feeding did not mean a compromise in the overall amount
of milk being consumed by the baby. The babies fed on demand got
an average of 73ml per feed (725 ml per day). While those fed at fixed
intervals got only 68.8ml per feed (502 ml per day). As a result, after
two weeks the babies on demand feeding gained significantly more
weight than the others. Furthermore the longer gaps reduce mothers
milk supply. The fat and energy content rises during the course of a
feed and an average hind milk has twice the fat and energy of
fore milk. Therefore, complete emptying of the breast is essential.
Breastfeeding
41
Mid Night Feeds

Most babies demand a midnight feed during their early weeks of
life. It may be exhausting for some mothers but babys need should
be met. However, it may be expedient to try to avoid the need for the
midnight feed by delaying the last feed by half to one hour before the
mother retires to bed, so that a more hungry baby obtains a larger
feed from the last feed and sleeps till early hours of the morning,
when the next feed becomes due.
Contraindications of Breastfeeding
There is no absolute contraindication of breastfeeding except breast
abscess. Though HIV transmission occurs through breast milk, WHO
recommends breastfeeding even in HIV positive mothers in
developing countries, because of higher mortality and morbidity in
non-breast-fed babies.
Breastfeeding should be slightly delayed in HBSAg positive
mother till the baby receives hepatitis-B immunoglobulin and
hepatitis vaccine. The baby delivered from mothers having congenital intrauterine infections such as CMV, toxoplasmosis, rubella,
herpes simplex, syphilis should also be fed with breast milk immediately as risks of acquiring infection through breast milk are least.
It may be desirable to avoid breastfeeding in following circumstances.
1. Maternal psychosis
2. Physically incapacitating illness
3. Mothers addicted to drugs or alcohol
4. Gross prematurity of the baby or mother conditions in which the
newborn cannot suck properly.
5. Breastfeeding may be deleterious in babies with certain inborn
errors of metabolism, e.g. phenylketonuria, glactosemia and
alactasia. Special formulae are usually indicated but with skilled
dietetic assistance breastfeeding may be achieved satisfactorily
in some babies with phenylketonuria.
Tables 10.1 to 10.7 should be useful in assessing transfer of drugs
and other chemicals into human milk.
TABLE 10.1: Cytotoxic drugs that may interfere with cellular
metabolism of the nursing infant
Drug
Reason for Concern, Reported Sign or Symptom in Infant, or
42

Effect on Lactation
Cyclophosphamide
Possible immune suppression; unknown effect on growth or

association with carcinogenesis, neutropenia
Cyclosporine

association with carcinogenesis
Doxorubicin*

association with carcinogenesis
Methotrexate

association with carcinogenesis; neutropenia
* Drug is concentrated in human milk.

TABLE 10.2: Drugs of abuse for which adverse effects on the infant during
breastfeeding have been reported*
Drug
Reasons and for Concern, or Reported effect
Amphetamine**
Irritability, poor sleeping pattern
Cocaine
Cocaine intoxication: irritability, vomiting, diarrhea,

tremulousness, seizures
Heroin
Tremors, restlessness, vomiting, poor feeding
Marijuana
Only 1 report in literature; no effect mentioned; very long

half-life for some components
Phencyclidine
Potent hallucinogen
* The Committee on Drugs strongly believes that nursing mothers should not
ingest drugs of abuse, because they are hazardous to the nursing infant and to
the health of the mother.
** Drug is concentrated in human milk.
TABLE 10.3: Radioactive compounds that require
temporary cessation of breastfeeding*
Compound
Recommended Time for

Ceasation of Breastfeeding
Copper 64(64Cu)
Gallium 67(67Ga)
Indium 111( 111 In)
Iodine 123(123I)
Iodine 125(125I)
Iodine 131 (131I)
Radioactivity in milk present at 50 h

Radioactivity in milk present for 2 wk
Very small amount present at 20 h
Radioactivity in milk present up to 36 h
Radioactivity in milk present for 12 d
Radioactivity in milk present 2-14 d, depending on study
Contd...
Contd...
Compound
Recommended Time for

Cesation of Breastfeeding
Breastfeeding
Radioactive sodium
Technetium 99m (99 mTc), 99mTc
Macroaggregates, 99 mTc 04
43
If used for treatment of thyroid cancer, high

radioactivity may prolong exposure to
infant.
Radioactivity in milk present 96 h
Radioactivity in milk present 15 h to 3 d
Consult nuclear medicine physician before performing diagnostic study so that

radionuclide that has the shortest excretion time in breast milk can be used.
Before study, the mother should pump her breast and store enough milk in the
freezer for feeding the infant; after study, the mother should pump her breast to
maintain milk production but discard all milk pumped for the required time
that radioactivity is present in milk. Milk samples can be screened by radiology
departments for radioactivity before resumption of nursing.
TABLE 10.4: Drugs for which the effect on nursing infants
is unknown but may be of concern*
Drug
Antianxiety
Alprazolam
Diazepam
Lorazepam
Midazolam
Perphenazine
Prazepam**
Quazepam
Temazepam
Antidepressants
Amitriptyline
Amoxapine
Bupropion
Clomipramine
Desipramine
Dothiepin
Doxepin
Fluoxetine
Fluvoxamine
Imipramine
Nortriptyline
Paroxetine
Sertraline**
Trazodone
Reported or possible effect

None
None
None
None
None
None
None
None
None
None
None
None
None
Colic, irritability, feeding and sleep disorders, slow
weight gain
None
None
None
None
None
Contd...
Contd...
Antipsychotic
44

Chlorpromazine
Chlorprothixene
Clozapine**
Haloperidol
Mesoridazine
Trifluoperazine
Others
Amiodarone
Chloramphenicol
Clofazimine
Lamotrigine
Metoclopramide**
Metronidazole
Tinidazole
Galactorrhea in mother; drowsiness and lethargy in

infant; decline in developmental scores
None
None
Decline in developmental scores
None
None
Possible hypothyroidism
Possible idiosyncratic bone marrow suppression
Potential for transfer of high percentage of maternal
dose; Possible increase in skin pigmentation
Potential therapeutic serum concentrations in infant.
None described; dopaminergic blocking agent
In vitro mutagen; may discontinue breastfeeding for
12-24 h to allow excretion of dose when signle-dose
therapy given to mother
See metronidazole
*Psychotropic drugs, the compounds listed under antianxiety, antidepressant,

and antipsychotic categories, are of special concern when given to nursing mothers
for long periods. Although there are very few case reports of adverse effects in
breastfeeding infants, these drugs do appear in human milk and, thus, could
conceivably alter short-term and long-term central nervous system function.
**Drug is concentrated in human milk relaltive to simultaneous maternal plasma
concentrations.
TABLE 10.5: Drugs that have been associated with significant effects on some
nursing infants and should be given to nursing mothers with caution*
Drug
Reported Effect
Acebutolol
5-Aminosalicylic acid
Atenolol
Bromocriptine
Aspirin (Salicylates)
Clemastine
Hypotension; bradycardia; tachypnea

Diarrhea (1case)
Cyanosis; bradycardia
Suppresses lactation may be hazardous to the mother
Metabolic acidosis (1case)
Drowsiness, irritability, refusal to feed, high-pitched
cry, neck Stiffness (1case)
Vomiting, diarrhea, convulsions (dose used in migraine
medications)
One-third to one-half therapeutic blood concentration
in infants.
Anticoagulant: increased prothrombin and partial
thromboplastin time in 1 infant; not used in United
States
Ergotamine
Lithium
Phenindione
Contd...
Contd...
Breastfeeding
45
Drug
Reported effect
Phenobarbital
Sedation; infantile spasms after weaning from milk.

Containing phenobarbital, methemoglobinemia (1 case)
Sedation, feeding problems
Bloody diarrhea (1 case)
Primidone
Sulfasalazine
(Salicylazosulfapyridine)
*Blood concentration in the infant may be of clinical importance.

TABLE 10.6: Maternal Medication Usually Compatible With Breastfeeding*
Drug
Reported sign or symptom in infant or effect on lactation
Acetaminophen
Acetazolamide
Acitretin
Acyclovir**
Alcohol (ethanol)
None
None
None
With large amounts, drowsiness, diaphoresis, deep
sleep, weakness, decrease in linear growth, abnormal weight gain; maternal ingestion of 1 g/kg
daily decreases milk ejection reflex
None
None
None
None
None
None
None
See Table 10.5
Suppresses lactation
None
Allopurinol
Amoxicillin
Antimony
Atropine
Azapropazone (apazone)
Aztreonam
B1 (Thiamin)
B6 (pyridoxine)
B 12
Baclofen
Barbiturate
Bendroflumethiazide
Bishydroxycoumarin
(dicumarol)
Bromide
Butorphanol
Caffeine
Captopril
Carbamazepine
Carbetocin
Carbimazole
Rash, weakness, absence of cry with maternal

intake of 5.4g/d
None
Irritability, poor sleeping pattern, excreted slowly;
no effect with moderate intake of caffeinated
beverages (2-3 cups per day)
None
None
None
Goiter
Contd...
Contd...
46
Drug
Cascara
Cefadroxil
Cefazolin
Cefotaxime
Cefoxitin
Cefrozil
Ceftazidime
Ceftriaxone
Chloral hydrate
Chloroform
Chloroquine
Chlorothiazide
Chlorthalidone
Cimetidine**
Ciprofloxacin
Cisapride
Cisplatin
Clindamycin
Clogestone
Codeine
Colchicine
Contraceptive pill with
estrogen/progesterone
None
None
None
None
None
None
None
Sleepiness
None
None
None
Excreted slowly
None
None
None
Not found in milk
None
None
None
Rare breast enlargement; decrease in milk production and protein content (not confirmed in several
studies)
None
None; follow up infants serum calcium level if
mother receives pharmacologic doses
Increased bowel activity
None; sulfonamide detected in infants urine
Crying, poor sleeping patterns, irritability
Cycloserine
D (Vitamin)
Danthron
Dapsone
Dexbrompheniramine
maleate
with d-isoephedrine
Diatrizoate
Digoxin
Diltiazem
Dipyrone
Disopyramide
Domperidone
Dyphylline**
Enalapril
Erythromycin
Estradiol
Ethambutol
None
None
None
None
None
None
None
None
Withdrawal, vaginal bleeding
None
Contd...
Contd...
Breastfeeding
Drug
47
Ethanol (cf. alcohol)

Ethosuximide
Fentanyl
Fexofenadine
Flecainide
Fleroxacin
None, drug appears in infant serum
None
One 400mg dose given to nursing mothers; infants

not given breast milk for 48 h
Fluconazole
None
Flufenamic acid
None
Fluorescein
Folic acid
None
Gadopentetic (Gadolinium) None
Gentamicin
None
Gold salts
None
Halothane
None
Hydralazine
None
Hydrochlorothiazide
Hydroxychloroquine**
None
Ibuprofen
None
Indomethacin
Seizure (1 case)
Iodides
May affect thyroid activity; see iodine
Iodine
Goiter
Iodine (povidone-iodine, e.g. Elevated iodine levels in breast milk, odor of iodine
in a Vaginal douche)
on infants skin.
Iohexol
None
Iopanoic acid
None
Isoniazid
None; acetyl (hepatotoxic) metabolite secreted but
no Hepatotoxicity reported in infants.
Interferon-
Ivermectin
None
K1 (vitamin)
None
Kanamycin
None
Ketoconazole
None
Ketorolac
Labetalol
None
Levonorgestrel
Levothyroxine
None
Lidocaine
None
Loperamide
Loratadine
None
Magnesium sulfate
None
Medroxyprogesterone
None
Contd...
Contd...
48
Drug
Mefenamic acid
Meperidine
Methadone
Methimazole (active
metabolite of carbimazole)
Methohexital
Methyldopa
Methyprylon
Metoprolol**
Metrizamide
Metrizoate
Mexiletine
Minoxidil
Morphine
None
None
None
None
Moxalactam
Nadolol**
Nalidixic acid
Naproxen
Nefopam
Nifedipine
Nitrofurantoin
Norethynodrel
Norsteroids
Noscapine
Ofloxacin
Oxprenolol
Phenylbutazone
Phenytoin
Piroxicam
Prednisolone
Prednisone
Procainamide
Progesterone
Propoxyphene
Propranolol
Propylthiouracil
Pseudoephedrine**
Pyrimethamine
Quinidine
Quinine
Riboflavin
None
None
Drowsiness
None
None
None
None
None
None; infant may have measurable blood
concentration
None
None
Hemolysis in infant with glucose-6-phosphate
Dehydrogenase (G-6-PD) deficiency
None
Hemolysis in infant with G-6-PD deficiency

None
None
None
None
None
None
Methemoglobinemia (1 case)
None
None
None
None
None
None
None
None
None
None
None
None
None
Contd...
Contd...
Breastfeeding
49
Drug
Rifampin
Scopolamine
Secobarbital
Senna
Sotalol
Spironolactone
Streptomycin
Sulbactam
Sulfapyridine
None
None
None
None
None
None
Caution in infant with jaundice or G-6-PD
deficiency and ill, stressed, or premature infant;
appears in infants milk
Caution in infant with jaundice or G-6-PD
deficiency and ill, stressed, or premature infant;
appears in infants milk
None
None
None
None
None; negligible absorption by infant
Irritability
None
None mentioned; drug not used in United States
None
None
Possible jaundice
None
None
Sulfisoxazole
Sumatriptan
Suprofen
Terbutaline
Terfenadine
Tetracycline
Theophylline
Thiopental
Thiouracil
Ticarcillin
Timolol
Tolbutamide
Tolmetin
Trimethoprim/
sulfamethoxazole
Triprolidine
Valproic acid
Verapamil
Warfarin
Zolpidem
None
None
None
None
None
*Drugs listed have been reported in the literature as having the effects listed or
no effect. The word none means that no observable change was seen in the
nursing infant while the mother was ingesting the compound. Dashes indicate
no mention of clinical effect on the infant. It is emphasized that many of the
literature citations concern single case reports or small series of infants.
**Drug is concentrated in human milk.
TABLE 10.7: Food and Environmental Agents: Effects on Breastfeeding
50
Agent
Reported sign or symptom in infant or effect on

lactation
Aflatoxin
Aspartame
None
Caution if mother or infant has phenylketonuia
Bromide (Photographic laboratory) Potential absorption and bormide transfer
into milk; see Table 10.6
Cadmium
None reported
Chlordane
None reported
Chocolate (theobromine)
Irritability or increased bowel activity if
excess amounts (< 16 oz/d) consumed by
mother
DDT, benzene hexachlorides,
None
Dieldrin, aldrin, hepatochlorepoxide
Fava beans
Hemolysis in patient with G-6-PD
deficiency
Fluorides
None
Hexachlorobenzene
Skin rash, diarrhea, vomiting, dark urine,
neurotoxicity, death
Hexachlorophene
None; possible contamination of milk from
nipple washing
Lead
Possible neurotoxicity
Mercury, methylmercury
May affect neurodevelopment
Methylmethacrylate
None
Monosodium glutamate
None
Polychlorinated biphenyls and
Lack of endurance, hypotonia, sullen,
expressionless
Polybrominated biphenyls
Facies
Silicone
Esophageal dysmotility
Tetrachloroethylene cleaning
Obstructive jaundice, dark urine
Fluid (perchloroethylene)
Vegetarian diet
Signs of B12 deficiency
Storage of Breast Milk

Breast milk can be expressed and stored in a clean container for later
feed if mother is working. It can be stored in refrigerator for up to 24
hours at 1 to 5oC. Breast milk can be frozen for up to 6 months (20oC). When frozen milk has to be used, it should be thawed in
refrigerator or in the luke warm water. It should not be kept at room
temperature for several hours to be thawed.
Measures to Increase Production of Breast Milk
1. Take simple, nutritious food in adequate quantities.
2. Drink sufficient quantities of pure water. Two litres of water
should be taken in the interval between two meals.
Breastfeeding
51
3. Avoid taking strong tea or coffee. Instead, take about a litre and a
half of milk.
4. If it agrees with you, form a habit of taking thin butter milk that is
not too sour.
5. Early in the morning, drink a litre of water with added lemon
juice. Drink two glasses of water or milk before breastfeeding the
baby.
6. Form a habit of going to bed early.
7. Use lemons and oranges freely in your daily diet.
8. Massage the breasts lightly every day.
9. Maintain a positive and optimistic frame of mind and concentrate on the thought that your breasts are going to produce plenty
of milk.
Some Common Problems Associated with Feeding
1. Hiccups: Hiccups are very common and occur regularly after
meals in the early months. Keeping the baby erect on shoulder
for sometime will solve the problem.
2. Regurgitation : Regurgitation is the spilling of stomach contents
gently out of the babys mouth. It is due to ingestion of air along
with milk. Burping and tapping the baby gently on the back is
sufficient.
3. Vomiting: Vomiting is the expulsion of stomach contents with
force to propel them at least few inches away from the mouth. An
occasional vomiting is not of concern but recurrent vomiting
should alarm the parent to consult a doctor.
4. Stools: Initially baby passes stool after each breast-feed, thus 6-10
stools in first month of life is normal.
5. Dehydration fever: At around 3rd or 4th day of life baby may
develop fever and drowsiness but after additional and frequent
breastfeeding, fever comes down to normal and baby begins to
feed normally. Additional water may be given.
6. Underfeeding: Underfeeding results in failure to gain weight. It is
common in top fed/formula fed due to ignorance, over dilution
and economic constrains.
Breastfeeding the Best Investment
Breastfeeding has been the most natural response of a mother to
satisfy the emotional and nutritional needs for her infant. This natural
food has proved to be the complete and protective food for the baby.
That this can even save us money, is perhaps not thought of. It
52
becomes important because health programs have interpreted

breastfeeding as preventive and promotive measures,without
highlighting that money spent and efforts made in this area can be
an effective investment opportunity to achieve savings on other
health care spendings and healthy returns for the nation.
Unfortunately efforts have not been made to look into the
potentials of investments to be made in this area with the wider
scope of savings and returns, not only in monetary and economic
terms but also in terms of building a healthy nation.
The protective effect of breastfeeding is silent and is done by the
regular supply of breast milk to the child from the day she/he is
born. The goodness and effectivity of the breast milk has long been
established for reducing diarrhea, pneumonia, improved child
nutrition and development along with its potentials in child spacing.
Breastfeeding as a National Resource
Breastfeeding is a natural resource that is frequently overlooked. In
some countries investing in its promotion has proven to be the most
cost-effective intervention for child survival, equal to conventional
practices such as immunizations and vitamin A supplementation
and oral rehydration therapy. Breastfeeding is priceless. Economic
measurements cannot put a value on any expression of love or
altruism.
The economic value of breast milk has been calculated to be Rs.
5916 to 11832 crores when priced at animal or tinned milk respectively. It can be compared with outlays of various developmental
sectors in the central plan outlay of the Government of India. It is
almost 10 times the allocation for department of women and child
development.
Cost of bottle feeding* a child for first six months
First Second
month month
Bottle
Nipple
Fuel
Powder milk
Third
month
Fourth
month
Fifth
month
Sixth
month
76
26
20
660
38
26
20
840
38
26
20
1020
38
26
20
1200
38
26
20
1200
38
26
20
1200
Total (Rupees) 782
924
1104
1284
1284
1284
Total
6662
*This cost does not include the time cost to purchase, prepare and administer
bottle feeds and cost of sickness that may occur.
Breastfeeding
53
The cost of artificially feeding a child for the first 6 months is

estimated to be an average of about Rs. 1100 per month, which is
equivalent to about 43 percent of minimum wages of a skilled worker,
25 percent salary of a class IV employee or 14 percent salary of a
school teacher. This is significant enough to pinch the household
budget of every family.
Common Faulty Feeding Practices Leading to Malnutrition
Malnutrition in children is a major concern, 47 percent children
under 3 years are under weight and 33 percent of all babies born are
low birth weight. Exclusive breastfeeding rate is only 19.4 percent at
6 months and 54.2 percent at 3 months and only 33 percent children
are being provided timely complementary feeding. Following faulty
feeding practices contribute to malnutrition.
1. Late initiation of breastfeeding
2. Giving babies other fluid and milks before breastfeeding is
initiated.
3. Starting artificial feeding before six months.
4. Early start of complementary feeding before six months.
5. Late introduction of complementary feeding.
Your work to improve feeding practices will help to reduce
malnutrition.
NUTRITIONAL COMPONENTS OF BREAST MILK
There is a large individual variation in the composition and energy
content of human milk. The fat and energy content rises during the
course of a feed and on an average hind milk has twice the fat of
fore milk. The level of most major nutrients and vitamins, with the
exception of lactose, falls during lactation.
Protein
The protein content of the mammalian milk affects the postnatal
growth rate of the infant. Human infants grow slowly in comparison
to other mammals, and breast milk is low in protein (approximately
1 gm/100 ml compared with 3.5 gm/100 ml in cows milk).
There are two main types of protein in the milk which are soluble
and casein which is insoluble and accounts for the white color of
the milk. Human milk contains 60 percent of its protein as whey. In
cows milk only 20 percent of the protein is whey, and the major
54
whey protein is beta-lactoglobulin, which is antigenic and absent

from the human milk. The cysteine content of human milk is twice
that of cows milk and methionine cysteine ratio is seven times
lower. Tyrosine and phenylalanine contents are low in human milk
and the human newborn has limited capacity to metabolize them.
Taurine, required for retinal development, is present in significantly
higher amount in human than in cows milk.
Fat
The average fat content of human and cows milk is similar and
consists mostly of triglyceride (98%). Human milk has a higher
proportion of unsaturated fatty acids than cows milk, and a greater
concentration of the essential fatty acids, linoleic and linolenic acid.
The long chain derivatives of essential fatty acids which are
important structural components of the brain are also present in
human milk. Evidence of essential fatty acid deficiency has been
seen in infants fed on unmodified cows milk exclusively during the
first 3 months.
Carbohydrate
Lactose is present in high concentration in human milk, it enhances
calcium absorption and helps to create a favorable gut flora that
protects against gastroenteritis (harmless lactobacilli predominate
in the stools of breast-fed babies, whereas klebsiella and Escherichia
coli predominate in formula-fed infants).
Energy
The energy of breast milk is about 70 kcal per 100ml. Minerals are
present in higher concentrations in cows milk than in human milk.
The high mineral and protein content of cows milk accounts for its
high renal solute load. Iron, zinc and other minerals are there in
greater quantity in mothers milk than in cows milk. Iron deficiency
anemia is common in infants fed on cows milk.
Growth Factors and Hormones
The following hormones and growth factors have been detected in
human milk, which may modulate neonatal metabolism and growth
process: epidermal growth factor, insulin like growth factor,
Breastfeeding
55
corticosteroids, thyroxine, gonadotrophins, gonadotrophin releasing

hormone, thyrotrophin releasing hormone, thyroid stimulating
hormone adrenocorticotrophin, prolactin, erythropoietin, melatonin,
prostaglandins and calcitonin.
Enzymes
The lipase in human milk plays a significant role in fat digestion in
breast-fed babies.
Vitamin K
Levels are low in breast milk as compared to levels in formula milk.
Hemorrhagic disease of the newborn is quite common in breast-fed
babies.
Vitamin D
In the human infant, cholecalciferol is derived mainly from the skin.
Breast milk provides 10 IU/day of vitamin D in winter and 20 IU/
day in the summer. An exclusively breast-fed healthy infant usually
has adequate bone mineralization and vitamin D status in the first
4-6 months; therefore routine supplementation during this period is
controversial.
Iron
When the infant has approximately doubled its birth weight, iron
stores present since birth become marginal unless supplemented.
The iron status may be low after 6 months of exclusive breastfeeding.
Iron deficiency may impair neurodevelopment and immunity
and is common in infants and toddler. In bottle-fed infant, continued
use of iron and vitamin C fortified formulas during infancy is effective
in preventing iron deficiency, but babies receiving breast milk for
longer than 6 months require iron-rich weaning food and
supplemental iron drops.
Fluoride
Infants living in areas with a fluorinated water supply (fluoride ion
0.3ppm) and consuming reconstituted formula milk will have an
adequate fluoride intake. In breast-fed babies, fluoride intake is low
and the recommended fluoride intake from 2 weeks of age is 0.25
56
mg/day. Fluorosis, with teeth mottling, may occur if the total intake
of fluoride exceeds 0.25 mg/day.
Protein and Energy
At 3 to 4 months of age, the intake of breast milk is about 750-850
ml/day (more in boys than in girls). At this stage, an average intake
of 150 ml/kg/day provides 1.5 gm/kg/day of protein and 85-105
kcal/kg/day, which are compatible with normal growth.
Breastfeeding is good for you and your baby. It will keep your
baby healthier.
Breastfeeding is recommended for the first year of life.
In the first month, the baby will need from 8 to 10 feeds per day.
Supplements are not usually needed during 1st 6 months.
Burp your baby often during feeding. More, if she is passing a lot
of gas.
Try different feeding positions to find the one that works best for
you and your baby.
Feeding and stools will be less often as your baby grows.
Breastfeeding
Promotion Network
of India
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Breastfeeding promotion network of India (BPNI) was founded on

3 December 1991 at Wardha, Maharashtra. This is a national
network of organizations and individuals dedicated to promote
mother and child health through protection, promotion and support
of breastfeeding BPNI is the regional focal point for the World
Alliance for breastfeeding Action (WABA) and International Baby
Food Action Network (IBFAN). This acts on the target of Innocenti
Declaration, convention of Rights of the Child and International
code and National Plan of Action for the child, India. This works
all over India through the education of people and health workers,
policy advocacy, training, social mobilization, information sharing
and monitoring the compliance of the Infant Milk Substitutes,
feeding bottles and infant foods (Regulation of Production, supply
and distribution) Act 1992 (IMSAct).
Goals
The goals of BPNI are to empower all women to exclusively breastfeed their children for the first 6 months and continue breastfeeding
till two years along with appropriate complementary foods started
at the age of six months.
Objectives
1. To advocate for sound policies on infant and young child
feeding.
2. To facilitate training of health professionals at hospitals,
community workers at grass-roots level in the management of
appropriate infant and child feeding practices.
3. To monitor compliance of the IMS Act.
58
4. To produce and disseminate accurate information on infant and

young child feeding.
Target Groups
1. Mothers for benefit of breastfeeding and dangers of bottle
feeding.
2. Health workers
3. Professional bodies
4. Infant food and breast milk substitutes industry
5. Employers
6. Ministry of Health
7. Ministry of Human Resource Development
8. Ministry of Information and Broadcasting
9. Public opinion
10. Academicians and researchers in India
Areas of Work
To achieve its objectives, BPNI works in following areas:
1. Training: BPNI works towards training of health professionals
and community workers to protect, promote and support
breastfeeding. BPNI coordinates and facilitates the education
and training of grass-root personnel in health and nutrition
sector and public and private hospitals as well. BPNI works to
enhance the quality of BFHI through improved training.
2. Information: BPNI works to provide accurate information on
breastfeeding at the local, state, national and regional level. The
maternal resource center for BPNI collects, uses and shares
informations to support state and national programs. Important
activities in this area include dissemination of materials
produced by BPNI, IBFAM and WABA and maintenance of a
website for information campaign.
3. Research: BPNI encourages research on breastfeeding and
complementary feeding issues and disseminates these findings
for protection and support of breastfeeding.
4. Women and work: BPNI supports special needs of working
women through advocacy work and information campaigns
towards ensuring their rights.
5. Monitoring and implementation of the IMS Act: BPNI works on
systematic monitoring in compliance with the IMS Act,
Breastfeeding Promotion Network of India 59

International code and subsequent World Health Assembly
resolutions. It provides information, training and develops
materials for all levels.
6. Education (Medical, Nursing and others): BPNI works to strengthen
basic curriculum on infant feeding at all levels.
7. Social mobilization: BPNI supports social mobilization towards
a breastfeeding culture for all communities all over India and
disseminates information to promote, protect and support
breastfeeding.
8. Policy and planning: BPNI works towards development of sound
infant feeding policies and also advocates for such policies with
the governments and other organizations.
TABLE 11.1: Success of BPNI effort in India
Level of area
Effect of BPNI work in India
Grass-roots
Exclusive breastfeeding and complementary feeding

indicators available at 3 and 6 months. Changes over
a period are also available: NFHS:1 and NFHS:2.
Infant formula industry
1. BPNI and ACASH gazetted under IMS Act 40

initiate legal action.
2. Restrictions on the promotion of infant formula,
infant foods and feeding bottles through IMS
Act.
3. Consumer groups, NGOs, trained to monitor the
IMS Act. Baby milk industry being monitored
by the NGOs like BPNI and ACASH.
4. Complaint against one major company pending
in court, many others have apologized, withdrawn their promotion or products, several
others served legal notices.
Health and nutrition

workers
1. Increased awareness, syllabus of ANM, AWWs

and health workers being changed to stress the
importance of and technique of breastfeeding.
2. Training of health personnel going on.
Professional bodies
1. IAP not accepting any funds from formula

industry and passed a resolution at AGM, 1997.
2. IMA declares that they do not accept any
funding from formula industry in 1995 and
circulated the decision to all branches. JIMA
agrees to take out a special issue on breastfeeding.
Contd...
60
Contd...
Level of area
Effect of BPNI work in India

3. FOGSI setup a committee to cover special issue
on breastfeeding after declaring 1999 as year for
breastfeeding.
4. TNAI takes active part in national programs
including BFHI.
Government
1. Ministry of women and child development

brings the IMS Act enacted in 1992, comes into
force in 1993.
2. Data about breastfeeding statistics included in
the demographic surveys, NFHS1 and 2 (1992
and 1993).
3. BFHI about 1400 hospitals declared baby
friendly.
4. Training of health professionals in breastfeeding
counselling to support BFHI.
5. Research into breastfeeding behaviors
6. Awareness campaigns.
NGO groups
1. Collaboration with other NGOs who are working and willing to work on breastfeeding and
complementary feeding.
2. Working with public service groups like Rotary
clubs on World Breastfeeding week celebration.
Consumer groups
1. Trained consumer groups on IMS Act, vigilant

groups available throughout India.
2. Collaboration and liaison with consumer groups
on the issue.
Politicians and
policy makers
Sensitized key MPs and MLAs and key policy

makers and members of Human Right
Commission.
Not Enough Milk
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Almost all mothers can successfully breast-feed their babies if they

are well informed and adequately supported. Breastfeeding is the
right of every mother and the child. Mothers, even in malnourished
states have demonstrated the ability to provide sufficient milk to
their babies because it is suckling that controls the whole process
of breast milk production and is the key to success.
Mothers say I dont have enough milk, this is the story in
every home in this world, rich or poor. The commonest reason by
mothers for introducing supplementary milk early or even
terminating breastfeeding, is the belief that she does not have
enough milk for her baby. This is sometimes represented as being
socially acceptable excuse for discontinuing, rather than being a
real problem. Sometimes relatives, friends or health workers
suggest to the mother that she may not have enough milk. Thus
the mothers confidence in her ability to meet the babys needs is
easily undermined when they ask a loaded question, is your baby
getting enough? this is enough to worry many mothers so much
that their milk production falls off and their babies dont get enough!
A babys need for milk and mothers ability to produce it just in
the right quantity have been said to be one of natures most perfect
examples of the law of demand and supply. Until the advent of
production of artificial milks, the very survival of the human race
depended largely on mothers ability to produce a sufficient quantity of milk to adequately nourish her baby. Breast milk production
increases when the baby suckles more due to increased secretion
of prolactin. This is the key to enough or even abundant breast
milk supply and a contented baby.
(Almost all mothers can produce enough breast milk for one or
even twins, provided the baby suckles effectively and breast-feeds
as often as needed).
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Practical Approach for Health Professionals

1. First, decide whether the baby is getting enough milk or not.
2. If the baby is not getting enough milk, evaluate why.
3. Decide how to help the mother and the baby.
Decide Whether the Baby is Getting Enough Breast Milk
Mothers can be confident that the baby is getting enough milk if:
i. The baby is gaining weight at an average of 500 gm per month
or approximately 20 gm a day (a weight loss of up to 10% is
considered normal during the first week of childs birth). In
order to establish that the weight gain has been appropriate,
at least two weights, at an interval of two weeks, need to be
compared.
ii. The baby is passing light colored urine six times or more a
day [6 wet langots (napkins) or more] and is receiving nothing
but breast-milknot even water or formula milk.
iii. The baby is breastfeeding frequently on both breast. Most
newborns usually breast-feed every two to three hours or 8 to
12 times in 24 hour period.
iv. The baby appears healthy.
If the Baby is not Getting Enough Breast Milk, Evaluate Why?
If a baby is not getting the breast milk it needs and is not gaining
weight adequately, try to understand why, listen to the mother
and learn about her situation. Try to understand why she believes
her milk is insufficient and what are her feelings about her baby
and about breastfeeding. Take history and observe a breast-feed.
Reasons Why a Baby may not Get Enough Breast Milk
Breastfeeding Factors
i. Delayed start
ii. Infrequent feeds
iii. No night feeds
iv. Short or interrupted feeds
v. Scheduled feeding
vi. Poor attachment
vii. Bottles, pacifiers
viii. Complementary feeds
ix. Top feeds
Not Enough Milk
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Mothers Psychological Factors

i.
ii.
iii.
iv.
v.
Lack of confidence
Worry, stress
Dislike for breastfeeding
Rejection of baby
Tiredness
Mothers Physical Condition

i.
ii.
iii.
iv.
v.
vi.
vii.
Using contraceptive pills, diuretics

Pregnancy
Severe malnutrition
Alcohol
Smoking
Retained piece of placenta (rare)
Poor breast development (rare)
Babys Condition
i. Illness
ii. Physical abnormality
Breastfeeding factors and mothers psychological factors are
common and often go together. If the first breast-feed is delayed
past few days, it is more difficult to establish a good milk flow,
which may affect the amount of milk the mother produces later.
Infrequent feeding, no night feeding and short or interrupted
feedings lead to less prolactin production and hence reduced milk
supply. Scheduled feeding interferes with the supply and demand
of milk production. The use of bottles and pacifiers may lead to
nipple confusion and addition of any other fluids/foods before six
months, would lead to less suckling stimulus, which in turn, will
lead to less prolactin production and hence, reduced milk supply.
The lack of confidence in the mother about her ability to produce
enough milk sets about a cycle of poor confidence, less secretion of
oxytocin, apparent poor milk supply, worried mother, crying baby
and introduction of bottle/artificial feeding. Promotion of infant
formula and free samples can further undermine mothers
confidence in her milk supply. Stress and worries also lead to poor
oxytocin reflex.
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How to Help the Mother and the Baby

If the baby is not getting enough breast milk:
i. Explain to the mother the possible reasons and reassure her
that her breasts can produce as much milk as her baby needs.
ii. Keep the baby close to her mother and not give her to other
care givers.
iii. Restore the mothers confidence. The baby should be allowed
to suckle uninterrupted more frequently and for as long as he
wishes.
iv. Reduce supplementary milk feeds and use a cup (not a bottle)
and this should be given/offered after the baby has breastfed for as long as he wants.
v. Avoid use of bottles, teats and pacifiers if artificial feeds are
needed.
vi. Follow up daily until the baby starts gaining weight, then
weekly until the mother has gained confidence and is satisfied.
A mother who thinks that she does not have enough milk
i. Explain to mother how breastfeeding works in milk
production.
ii. Help mother to improve babys attachment at the breast.
iii. Build her confidence and show her that the baby is gaining
weight. Reassure that the baby is getting enough milk.
iv. Babies cry a lot when hungry. The commonly used methods
to comfort the baby who cries a lot.
a. Hold the baby
b. Stroke him gently
c. Put light pressure against the abdomen
d. Change his/her clothes
e. Burp the baby several times during a feed
f. Sometimes a change of place.
v. Explanation regarding advantages of exclusive breastfeeding
and the dangers of unnecessary supplements.
vi. Inform the mother about how breastfeeding works and role
of let down reflex and how confidence can help her to come
out the problem.
vii. Talk to close relatives.
viii. Follow-up each, until mother has gained confidence.
ix. The main way to increase the supply of breast-milk is for the
baby to suckle to stimulate milk production.
Questions and their

Answers on
Breastfeeding
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All mothers and babies are different. Try not to worry about what
others are doing. The following answers would help the mothers
to reassure themselves
Can All Women Breast-feed?
Almost every women can breast-feed, but it can sometimes take a
little while to get it right. Be patient and ask your midwife or health
visitor for help if you need it.
Does Breast Size Matter?
No. All sizes and shapes make milk.
Can Flat or Inverted Nipple be a Problem?
Not necessarily but you will need extra help in learning to position
your baby.
Do I Need to Prepare my Breasts for Breastfeeding?
The production of milk is a natural process. You dont need to do
anything but it is a good idea to try and keep your skin soft and
supple so avoid soaps and sprays that have a drying effect.
Do I Need to Watch What or How Much I Eat?
Eat and drink when you feel you need to. Sometimes you may find
you are hungrier and thirstier because breastfeeding uses up
calories and fluid.
Can I Go out Without the Baby?
Yes. You can always express some of your milk and leave it for
someone else to feed your baby. Ask about expressing milk and
storing it.
66
How can I Make Sure that My Baby Feels Involved?

Breastfeeding is the only way to be close to a baby. Babies need
cuddling, bathing and lots of attention.
Is it Worth Breastfeeding if I Am Going Back to Work Soon?
Definitely. The early weeks at home are the time when breast milk
does most good. After that you can express milk when you are at
work and breast-feed when you are at home.
What about Feeding My Baby in front of Friends or in Public?
You may feel comfortable about feeding in front of others. If you
feel uneasy, it is not difficult to feed your baby discreetly under a
loose top, T-shirt or half-unbuttoned blouse. Dont be embarrassed
to ask if there is a mother and baby room when you are out.
How Will I Know if My Baby is Getting Enough Milk?
The sucking process releases milk to satisfy your baby and stimulates the production of more when your baby is full up, he or she
will stop feeding. Signs that your baby is getting enough milk are
passage of light colored urine six times or more without getting
any other drinks and gaining weight.
How Long Should I Go on Breastfeeding?
You can go on breastfeeding for as long as you want to but at least
five minutes on each breast.
Is there any Drug that may Increase Milk Supply?
Some drugs have been reported to increase supply but frequent
suckling at the breast and avoiding bottle feeds is enough to ensure
adequate supply of milk than medicines. Metoclopramide is known
to enhance prolactin secretion but does not replace counselling to
build confidence in mothers.
To Increase her Milk Supply, Should the Mother Drink Large
Amount of Extra Fluid?
Drinking to quench thirst is sufficient. No benefit was observed
with a marked increase in supplemental fluid intake.
When Does the Lactating Mothers Milk come in?
Colostrum, a highly concentrated source of protein and antibodies,
is produced as early as third month of pregnancy and continues to
Questions and their Answers on Breastfeeding
67
be produced through the second week of the infants life. Milk truly
starts flowing on day 3 onwards.
Breastfeeding should be initiated within first half an hour of
birth.
Baby Wants to Suckle Only one Breast and not the Other, What
should Mothers do?
Breast preference is known. The baby may not want to suckle one
of the breasts if it finds easier to suckle the other breast or does not
get milk from the first. This may happen if your nipple is sore or
the breast is engorged. Expressing some milk before starting
breastfeeding will help you. You should start breastfeeding from
the breast that the baby likes to suckle and wait for the milk from
the other breast to flow, then the baby will find suckling easier and
satisfying. You should not give up easily.
When I Feed the Baby, There is a Gush of Milk and My Baby
Chokes. What Should be Done to Solve this Problem?
Some mothers have a strong let down reflex so when the baby
suckles, there is a gush of milk, which is too much for the baby to
handle and thus he/she chokes. Express your milk a few second
first and offer the baby your breast.
Look What Breastfeeding Does for You !
Saves money
Reduces the risk of early breast cancer
Helps you lose weight
Less-offensive nappes
Better Still for Your Baby

Gives your baby the perfect diet, anytime, anywhere.
Convenientinstantly available at right temperature.
Less illnessbreastfeeding reduces the risk of diarrhea and
chest infection.
Gives a closeness that your baby thrives on.
Give it a TryYou and Your Baby Love it
Breastfeeding
Questions and their

Answers on
Bottle Feeding
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If Mothers Choose to Bottle Feed,

What Type of Milk can be Given to the Baby?
If you have decided to bottle feed your baby, it is important to
choose the correct type of milk for your babys age. Up to six months
of age, the only milks which are suitable for babies are breast milk
and baby milk. From six months, you can choose a follow-on milk.
Which Type of Baby Milk should be
Chosen if Baby is 0-6 months Old?
First milks are the most suitable for young babies as they are
made to closely resemble breast milk.
Should Mothers use Powder or Liquid?
If you decide to bottle feed your baby in hospital, you should use
baby milk in 100 ml bottles which are ready to use. These little
bottles should not be taken home. They are designed to be
disposable and may crack or break if used more than once.
Ready-to-use milk can be used for individual feeds. The little
cartons can be ideal as stand byes for breastfeeding mums, for
baby sitters, for emergencies if you are concerned about water
purity or while travelling.
Can Mothers Give their Baby Cows Milk and if So, When?
Until the baby is 6 months old, the only milk to be given is breast
milk or baby milk. Other types of milk are not suitable as they will
not meet the babys nutritional needs and can make him ill.
Cows milk should not be used as a milk drink until baby is at
least 1 year old as it is low in some essential vitamins and minerals
Questions and their Answers on Bottle Feeding
71
such as vitamin A, D and iron. So you have to give additional

supplement of vitamins A and D and iron.
Semi-skimmed milk should not be used until baby is 2 years
and skimmed milk should not be used until the age of 5 years as
fat contents are low and will not provide the baby enough energy.
What should I Use If I Think My Baby is Allergic to Milk?
Many people believe that goats and sheeps milk can be used for
babies who are allergic to cows milk. However, this is not true,
babies who are allergic to cows milk are likely to be allergic to
these types of milk too. It is not advisable to use either type of milk
for babies until they are at least 1 year old.
I think your baby may be allergic to milk, you must consult
your doctor before changing babys feed. They may recommend
special milk such as lactose free milk or Soya baby milk but this
must be used under medical supervision.
How do Mothers Prepare the Powdered Feed for Baby?
Full instructions are always given on the container and it is essential
to follow them exactly. Cleansing and sterilizing equipment is
equally important to protect the baby from harmful germs. You
must ensure that your work surfaces and hands are clean.
How do Mothers Clean and Sterilize Feeding Equipments?
First wash all equipment thoroughly in hot water, then scrub the
bottles with a special bottle brush so that all milk is removed from
teats, thereafter rinse bottles and teats thoroughly with clean water.
Common salts may be used to clean teats but rinse teats properly
before sterilizing.
i. Boiling everything in a large sauce pan with the lid on for 3
minutes, making sure that bottles, teats and caps are fully
immersed in the water.
ii. Steam sterilizer unit
iii. Cold water sterilizing tankplace either sterilizing tablets or
fluid in water. Then fully immerse the equipment and leave
for about 30 minutes.
iv. Sterilization may be done with microwave steam sterilizer.
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Can Several Feeds be Prepared at Once and Stored ?

Yes, feeds for the whole day may be prepared at once. Ensure that
they are stored in the freeze and thrown away if not used within 24
hours. Let the bottles of the milk cool down before storage.
How the Fuss of Feeding at Night can be Minimized
This can be minimized in two ways either by taking a previously
prepared feed from the freeze to the bedroom to heat up when
needed or by making up a sterilized thermos flask of freshly boiled
water each night and keeping this beside your bed so that you can
mix up the feed when needed.
The feed should never be made up and kept warm in a flask
and bottles of made up milk should not be stored in a bottle warmer
because it may allows germs to breed and make your baby ill.
Do Babies Need Extra Vitamins during Bottle Feeding?
No. All baby milks contain vitamins and minerals for babys needs.
If your baby is taking less than 500 ml a day, extra supplements
may be necessary.
Why do Babies Seem to Cry Persistently?
Cry is the main way of communication in babies. Check things that
could be wrong
i. Is your baby warm and comfortable?
ii. Is nappy dry?
iii. If crying after a feed, is he/she still hungry?
iv. Could baby be thirsty?
v. Is it wind?
If you have checked above mentioned things and cry is
inconsolable, discuss the problem with your health care
professional.
Is it Necessary to Burp or Wind a Baby After Every Feed?
No. It may not be necessary, but it is always worth a try, because it
is much worse to put a baby down to sleep and then have him
wake up crying soon after because he has a wind.
Questions and their Answers on Bottle Feeding
73
Baby is Sometimes Sick After Feed, What Causes this?

Most babies bring up a little milk while burping. This is called
positing and it is perfectly normal. If, the whole feed comes up,
there could be several reasons: the hole in the teat is too big, the
baby may have swallowed too much air or burped too enthusiastically. If this happens constantly, try to contact your doctor.
How can Bottle teat be taken out Easily After Feeding?
Dont pull teat away abruptly. Just move the teat gently around
babys mouth. This breaks the suction, so you can gently slide the
teat away.
When Should Weaning be Started on to Solids?
Most babies should start on solids between 4-6 months of age. It is
a gradual process which extends over a period of weeks or months.
Early weaning before 4 months is not advisable because babys
digestive system is not developed enough to cope with solid foods.
How Long Should Baby be Fed with Baby Milk?
Experts recommend that it is best to continue feeding with baby
milk until your baby is at least one year old. This ensures that babies
weaned continue to receive a supply of vitamins, minerals and
energy from their formula milk.
What are the Features of Upset of Bowels in the Baby?
Babys stools can be anything in color from yellow to green to
brown. The color of your babys stool is nothing to be concerned
about, as long as your baby is healthy and thriving. If babys stools
become slimy, foul smelling, watery or runny, then consult your
doctor immediately.
What Should be Done if Baby is Constipated?
True constipation in babies is rare. The baby is truly constipated if
there are signs of discomfort while passing stool and if stools passed
are small and hard, like pellets or peanuts.
Check that feeds are being made correctly and are not over
concentrated. Ensure that your baby is being fed on demand and is
74
taking as much as he wants at each feed. Do not try to force extra

milk into your baby or take the bottle away too early; let him/her
decide how much and when.
Some people say that adding sugar to the feed can cure constipation. This is certainly not a practice which is recommended and
you should avoid it. Instead try offering small drinks of cooled,
boiled water between feeds. If your baby continues to have hard
stools, consult your health care professional.
How can I Judge that the Baby is of
Right Weight for his Age?
Dont be over concerned about your babys weight. Babies are
weighed frequently to check for any serious problems, but remember, all babies are different and some just do grow faster than others.
A guide to normal weight gain is that you can expect your baby
to roughly double his birth weight by 6 months and treble it by a
year. As long as your baby is happy and healthy, you dont need to
worry, but if you are concerned, mention it at a baby clinic.
Jaundice in Newborn
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Jaundice as a sign of disease was mentioned in ancient literature

by Hippocrates and Galen. Williams Potts Dewees wrote in 1825
that jaundice in the newborn is but too often fatal, with whatever
propriety or energy we may attempt to relieve it. Virchow, in 1847
observed the accumulation of microscopic yellow crystals formation
in bruises, in wound fluid and in the subcutaneous hematomas
following phagocytosis of red blood cells. This observation
provided the first experimental evidence for a link between
bilirubin and heme. Since that time much effort has been spent
exploring the various aspects of this relationship including
mechanisms that control or influence the chemical reactions and
clinical consequences associated with the presence of bilirubin in
vital organs.
Benefits of Bilirubin
Bilirubin was previously considered mere useless catabolic waste
product but is recently considered as antioxidant and protects
neonates and children from injury by reactive oxygen free radicals
which are considered as contributing or exacerbating factors for
chronic lung diseases in newborns.
Jaundice is the commonest abnormal physical finding of parents
concern during the first week of life. Approximately two-thirds of
newborns develop clinical jaundice. The progression of jaundice
occurs in cephalocaudal direction, i.e. from head to toes, because
of relative thickness and lipid content of skin. The skin is thinnest
over the face, therefore jaundice appears first on the face. The
severity of jaundice should be assessed in natural daylight. The
yellow staining of palms and soles indicates very high bilirubin of
the baby and parents should consult doctors immediately.
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COMMON CAUSES OF JAUNDICE IN NEWBORN

a.
b.
c.
d.
e.
f.
Physiological jaundice (most common)

Blood group and Rh-incompatibility
Septicemia
Intrauterine infections and neonatal hepatitis
Breast milk jaundice
Obstruction to biliary channels.
Physiological Jaundice
This is seen in approximately 60 percent term and 75 percent of
preterm babies. The postulated causes are physiological immaturity
of liver, polycythemia and reduced life span of red blood cells. In
term babies, this appears between 32 to 72 hours of age, peaks on
4th or 5th day and usually disappears by 10 day and in preterm by
14 days. Physiological jaundice is a harmless condition. There
should not be any anxiety for parents.
Pathological Jaundice
Pathological jaundice refers to jaundice in newborns that appear
within 24 hours of delivery or persists for more than 14 days. Parents
are advised to contact their doctor immediately.
Breast Milk Jaundice
Breast milk jaundice may manifest as persistence of physiological
jaundice or it may appear for the first time at the end of first week.
The maximum intensity is usually seen between 10 to 14 days and
may last for 6-10 weeks. The etiology is multifactorial and includes,
dehydration during first few days due to inadequate lactation,
delayed colonization of gastrointestinal tract, high concentration
of unsaturated fatty acids in breast-milk and defective conjugation
due to presence of 3-alpha 20-beta pregnanediol.
Blood Group and Rh-incompatibility
Incompatibility of blood groups and Rh-type are the commonest
cause of jaundice during first 24 hours of birth and is the most
common cause of insult to developing brain leading to kernictenes.
In central nervous system bilirubin gets deposited especially in
Jaundice in Newborn
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basal ganglia, pons and cerebellum. Infants, who develop

kernicterus, 50 percent die and survivors may have choreoathetoid
cerebral palsy, nerve deafness and mental retardation. The
recognizable clinical manifestations in newborns are rigid extension
of all four limbs, tight-fisted posturing of arms, opisthotonos,
crossed extension of the legs and high pitched irritable cry.
In majority, the cause of jaundice is physiological, hence do not
need any investigations. The laboratory investigations are indicated
in following situations:
a. History of severe jaundice in previous sibling
b. Mother with blood group O or Rh-negative.
c. Onset of jaundice within 24 hours or jaundice beyond 14 days.
d. Palm and soles distinctly yellow stained.
e. Sick and jaundiced baby
f. Yellow colored urine or clay colored stool.
Suggested Laboratory Investigations
a.
b.
c.
d.
e.
f.
Blood grouping and Rh-typing of baby and mother.

Serum bilirubin, both direct and indirect
Peripheral smear for evidence of hemolysis
Hemoglobin
Reticulocyte count
Sepsis screen : TLC, Absolute neutrophil count, Band cells, toxic
granules, CRP and micro-ESR.
g. Ultrasonography of hepatobiliary system.
Management
The objective of treatment is to keep serum bilirubin at safe level
and prevent brain damage. This is to remember that jaundice
(pathological) is an emergency and delay in treatment may lead to
irreversible brain damage or death. The treatment of jaundice
includes:
1. Avoid dehydration by frequent breastfeeding or formula
feeding or IV fluid.
2. Exposure of baby to morning sunlight for at least one hour but
there may be associated risk of hypothermia.
3. Aspiration of cephalhematoma if present.
4. Treatment of associated infections with antimicrobials, if
present.
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5. Phototherapy or exposure of infant to common bulb (200 watt)

continuously.
6. Exchange transfusion.
7. Drugs
a. Phenobarbitone: 10 mg/kg im or 5 mg/kg/day in two
divided doses. This causes enzyme induction in liver.
b. Tin-mesoporphyrin: It is the inhibitor of heme oxygenase
enzyme and thereby blocks production of bilirubin. The dose
is 6 mmol/kg im single dose. Therapy is associated with
high risk of skin rashes, hepatic and renal toxicity.
c. Agar, cholestyramine and orotic acids are rarely used.
Prevention
1. Prevention of Rh-isoimmunization: The administration of antiD immunoglobulin to Rh-negative non-immunized mother soon
after birth of a Rh-positive baby will immediately destroy the
Rh-positive fetal blood cells which might have seeped into
maternal circulation. The protective efficacy has been reported
up to 98 percent.
Prophylactic anti-D immunoglobulins are indicated in
following situations to mother:
a. After birth of Rh-positive baby.
b. After abortion of Rh-positive conceptions
c. Amniocentesis, chorionic villus biopsy and manual removal
of placenta from Rh-negative mother.
Dose of anti-D immunoglobulin
a. After delivery: 250 microgram im single dose.
b. Abortions: within 72 hours of delivery.
c. Amniocentesis and other procedure: 50 microgram im single
dose.
2. Blood grouping and Rh-typing of mother during antenatal
period.
3. Blood grouping of babies immediately after birth.
4. Avoid large doses of vitamin-K.
5. Perinatal distress factors such as hypoxia, hypothermia and
hypoglycemia should be prevented or managed with oxygen,
proper covering and kangaroo care and early frequent breastfeeding of babies.
Neonatal Skin Care and

Diaper Dermatitis
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The intact skin in human beings is essential as it acts as an interface

between the internal milieu and the environment and provides
following important functions.
1. Temperature regulation and minimization of calorie losses.
2. Prevents transepidermal water losses and protects against
dehydration.
3. Electrolyte homeostasis.
4. Defense against microbial invasion.
5. Protection from environmental toxins.
6. Protection from ultraviolet radiation.
7. Tactile sensation and.
8. Protection from trauma.
The developmentally mature and intact stratum corneum
effectively prevents infection of the skin and impedes microbial
invasion mechanically or through its acidic pH or by release of
antibacterial products including cytokinins. Neonates, especially,
preterm infants are at high risk for infection because of epidermal
barrier immaturity, developmental defects in systemic immune
function and disordered cutaneous immunoregulatory function.
Approximately 80 percent of newborn develop a skin problem, i.e.
rash during first month of life but little information is available for
rational approach to skin care. The instructions and recommendations for skin care of neonate at home and hospitals are the
following.
Hygiene of Care Givers
Attendants and mothers are thought to be the most common
environmental source of colonization of neonatal skin which in turn
may predispose to infection. Handwashing is the simplest and most
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cost effective way to prevent skin colonization and interrupt nosocomial transmission.
1. Chlorhexidine and a waterless, alcohol based product are agent
of choice for handwashing.
2. The routine use of plain soap for hand washing should be
avoided as it may result in dispersal of bacterial colonies and
increase the risk of transmission.
3. The baby should be handled only after proper hand washing.
Umbilical Cord Care
Hygienic umbilical cord care can reduce umbilical colonization,
infection, neonatal tetanus and sepsis in developing countries. The
recommendations for umbilical cord care are the following:
1. The diaper should remain folded and away from stump to
facilitate drying.
2. The application of emollients such as oils, gelly, etc. to stump
should be avoided.
3. The umbilical stump should be washed morning and evening
with antiseptics such as chlorhexidine, spirit and povidone
iodine.
4. There is no role of antimicrobial application on stump.
5. There should not be dusting of umbilical stump with commercial
talcum powders.
Bathing
Bathing the newborn has many potential hygienic, cultural,
aesthetic and interpersonal benefits. Bathing newborns after birth
is unnecessary and, if not performed properly, may cause more
harm than good. This may be accompanied by hypothermia and
increased crying with increase in oxygen consumption and
respiratory distress. Guidelines for bathing newborn infants include
the following:
1. The first bath should be delayed until after vital signs have been
stable for several hours.
2. Mothers and health care workers should have clean hands,
before and during bath to prevent exposure to pathogens.
3. Excessive vernix may be removed, but in general, is best left on
skin.
Neonatal Skin Care and Diaper Dermatitis
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4. For first bath in term baby, use a dilute (1:20) aqueous solution
of chlorhexidine (0.25%), followed by thorough rinsing with
plain water. The preterm baby should be bathed with sterile,
lukewarm water for removal of maternal bodily fluids.
5. For routine bathing during first 2-4 weeks of life, plain warm
water should be used for premature infants whereas immersion
bathing up to three times per week in term infant may be more
soothing and have more positive effects on skin.
6. A mild neutral pH soap without additives should be used if
necessary in high soiled areas.
7. Rubbing or scrubbing during bathing may injure the epidermis
and should be avoided.
8. The skin should be rinsed well after bathing especially in preterm and after using antiseptics.
Emollition
The newborn skin is drier and has reduced water-holding capacity
compared to children and adults. The hydration of skin is important
for maintenance of its integrity and function as a barrier. The agents
that can be used as emollients are vegetable oils rich in essential
fatty acids such as sunflower-seed oil, mustard oil and safflower
oil. The benefits of emollient applications include:
1. Temperature maintenance of baby
2. Nutrition through transcutaneous absorption of lipids
3. Enhanced neurologic development and promotion of motherinfant bonding
4. Normalization of transcutaneous water losses and resolution
of dermatitis
5. Improved skin hydration and surface lipid content
6. Decreased invasive infections in preterm infants.
The use of barrierenhancing emollients in care of neonatal
skin is now recommended and practised routinely in many NICU
especially for preterm baby and in all infants with dry, flaking or
fissure skin. The application should be done in a gentle, uniform
manner because frictional forces during application may cause skin
injury.
Excess oiling without proper bathing is harmful because of
increased colonization of bacteria and enhanced susceptibility to
seborrhoeic dermatitis and cradle cap.
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Diapering and Diaper Dermatitis

The most common form of diaper dermatitis can be recognized by
its characteristic pattern of erythema over lower abdomen, genitalia,
buttocks and upper thighs and sparing of the inguinal creases and
the gluteal cleft. In more severe form, erosions and ulcerated
nodules can occur. This is due to increased moistness of skin and
elevated pH caused by urinary ammonia thus results in activation
of fecal proteases and lipases in alkaline environment. When
alkaline urine combines with feces, the potential for irritation is
compounded.
The treatment of diaper dermatitis should be aimed towards
reducing skin moistness, minimizing contact of skin with urine and
feces, and eradicating infecting organisms. The ways to reduce
moistness and irritation include:
1. Use ultra-absorbent diapers (commercial diapers should be
avoided).
2. Frequent change of diapers.
3. Application of barrier ointments such as petroleum jelly, help
to keep urine and feces from contacting skin.
4. Commercial products containing zinc, vit-A and vit-D are also
effective.
5. One percent hydrocortisone ointment may be applied if inflammation is significant.
6. Combination antifungal-steroids should not be used in treating
neonatal skin conditions.
7. The use of powders also should be avoided.
8. Fungal and bacterial superinfection may be managed with
appropriate topical agents.
9. Neomycin carries a higher risk for allergic contact sensitization
and should be avoided.
Agents
1. Povidone iodine
(Betadine)
2. Corticosteroids
3. Neomycin
4. Triple dye
Untowards effects in neonates

Hypothyroidism and goiter
Skin atrophy, striae, adrenal suppression, Cushings
syndrome, acneform rash and telangiectasia
Contact dermatitis, neural deafness
Skin necrosis
Contd...
Neonatal Skin Care and Diaper Dermatitis
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Contd...
5.
6.
7.
8.
9.
Agents
Untowards effects in neonates
Gentian violet
Boric acid
Lindane
Glycerin
Methylene blue
Nausea, vomiting, diarrhea, mucosal ulceration

Vomiting and diarrhea, seizure
Seizure
Seizure
Methemoglobinemia
In neonatal period, many newborns develop preventable and

clinically apparent skin problems. The awareness among mothers
and health care providers for optimizing skin integrity in neonates
is important for improving neonatal health.
Weaning
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Breastfeeding alone is sufficient food for all babies till 6 months of

age. From 6 months, complementary foods are required to ensure
adequate growth and to prevent malnutrition and stunting. In order
to feed babies appropriately, we need to know the age of introduction of weaning, type, texture, frequency, amount of food and
method of feeding.
6-11 months period is an especially vulnerable time because
infants are just learning to eat and must be fed soft foods frequently
and patiently. Care must be taken to ensure that these foods
complement rather than replace breast-milk. For older infants and
toddlers, breast-milk continues to be an important source of energy,
protein, vitamin A and vitamin C. Therefore breastfeeding should
be continued upto the age of 2 years along with complementary
feeding. All health care providers should counsel mothers with
regard to complementary feeding.
Age of Introduction
Sufficient scientific data is now available to support that exclusive
breastfeeding should be continued till six months and complementary foods added to breast-milk after 6 months. Initiating
complementary foods too early or too late can lead to malnutrition.
If given too early, the infant may not be ready to digest the food
properly and may also reduce intake of breast-milk, thereby losing
out energy intake for growth. It also increases the risk of diarrhea
and other infections. After six months, the breast-milk can not
supply all the needs of the growing baby. Introduction of complementary feeds too late results in an inadequate intake of energy
Weaning
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and protein leading to poor growth as well as iron and other

nutritional deficiencies.
FOR ALL INFANTS AFTER 6 MONTHS
OF AGEWHY AT 6 MONTH?
By 6 months, an infant can voluntarily control sucking and swallowing and biting movements begin. The tendency to push solid foods
out of mouth decreases. Teeth begin to erupt and pancreatic
enzymes reach adequate levels for digestion of starch. By the age
of 9 months an infant can use lips to clear a spoon and use the
tongue to move food between teeth. Solids can also be chewed at
this age. This means that from 6 months, a child can eat soft and
starchy foods such as cereals. By 9 months, infants can be given
chipped foods.
Taste, Consistency, Texture and
Types of Complementary Foods
Babys first food should be based on cereals like suji or fruit like
banana which are soft, thicker than breast-milk and bland in taste,
mashed or strained to homogenize.
The consistency of food should be suitable as per the childs
age. For very young infants, liquid supplements should be given
and their consistency gradually need to be changed from liquid to
semisolid and then to solid with advancing age of the child. Initially,
a baby might spit out the food. That does not mean the baby does
not like it, learning to swallow semisolid food is difficult for a baby
who only knows how to suckle at the breast. Husks, bean skin and
vegetable fibers may cause indigestion, so everything must be
mashed at the beginning.
The prerequisite of a good weaning food is to meet the nutritional needs of the child. No single food can meet all the nutrient
requirements. Essential nutrients are widely distributed in nature
and can be obtained from various sources. Also, most of the foods
contain more than one and quite often, many of the essential
nutrients in varying proportions. Therefore to achieve a balance of
nutrients, foods should be included from all three food groups
(energy giving, body building and protective) in the diet.
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Table 18.1
Foods
Major nutrients
Functions
Milk
Meat
Pulses
Protein
Body building
Cereal
Starches
Fat/oil
Sugar
Carbohydrates and
Fat
Energy giving
Vegetables
Fruits
Minerals, vitamins and

Dietary fibers
Protective
Source: Adapted from Textbook of Nutrition and Dietetics, Department of Food

and Nutrition, University of Delhi.
Tips About Weaning Foods

1. Carrot, beans, potatoes can be easily cooked along with Dal and
rice and mashed to desired softness to feed the young child.
2. Adding oil or butter to cooked and mashed food is a good way
to increase energy density.
3. During illness, give small frequent meals along with breast-milk.
4. Avoid spices and chillies.
5. When introducing fresh fruit in the diet, mash it for easy feeding.
6. If a food makes the baby sick or turn pale, it should not be given
till the baby is older.
7. Offer home made family foods as they are nutritious. Commercially processed foods are seemingly convenient but are not
better or even equal to home made foods and 6 times more costly
as well.
Frequency of Foods
When food is first introduced, a small amount should be given one
to two times a day. From 6 months to one year, adequate foods
should be given thrice a day and gradually the amount should be
increased. If the baby is not breast-fed, weaning foods should be
given five times a day. It is advisable to continue frequent breastfeeding including night breast feeds up to two years of age.
Feeding Practice
Children can usually feed themselves by one year of age but they
need supervision and help.
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Tips
Mothers should introduce one food at a time.
Let your baby go at his own pace do not compare him to his
little friend!
The child should not be fed forcibly. Dislike of any particular
food by baby should be removed from babys diet.
Variety should be introduced in the childs diet to make it more
appealing.
Color, flavor, texture and shape of the food can be given special
consideration, so as to attract childs attention in older children.
Parents should not show personal prejudices and dislikes
towards any food.
The baby will only eat when he is hungry, so if he shakes his
head, spits food out and so on, just stop. It is important that
meal times are seen as relaxed enjoyable times.
Communicate with child during meal times.
It is not always necessary to cook separately for the child, as
the family meals can be easily modified in consistency, spicing
etc. for the amount needed to feed the child.
Feed slowly and patiently and minimize distractions during
meals.
Encourage the child towards self eating.
Hygiene and Care
When a child starts complementary food, there is increase in the
risk of diarrhea. Care should be taken to prepare and handle food
hygienically. It is advisable to feed the child fresh food and keep
food away from flies, insects and pets. Cooked food should be used
within a few hours.
Foods to Avoid
Meat, eggs, dairy foods, cows milk, bread/cereals containing wheat
(gluten) should not be included in babys diet at 6 months of age.
How to Start ?
The following tips will help those early weaning sessions go more
smoothly.
1. Avoid starting weaning at awkward times such as holidays or
during hot weather when your baby may become fidgety.
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2. Choose a time when you are not in a hurry and your baby is not
too hungry the middle of the day is often best.
3. Get every thing you need ready before you start and remember
to put a bib on your baby.
4. Put your baby on your lap or in his baby seat.
5. Give your baby most of his milk feed, then after a little solid
food on the end of a small plastic spoon. If he spits it out, scoop
it up and try again but do not force.
6. Once your baby is taking one to two tablespoons of food at
feeding time, offer him a second solid feed each day.
Solid Foods
4 to 5 months: Begin solid foods with rice cereal mixed with
formula.
5 to 6 months: Add strained vegetables one at a time.
6 to 7 months: Add strained fruits and juice
7 to 8 months: Add strained meats.
Serve solids from a spoon, never a bottle.
Offer one new food at a time. Wait at least 3 days before trying
another one.
As more solid foods are eaten, less breast-milk or formula is
needed.
Feeding Your Child (from 1 to 5 years)
Your child needs 3 meals a day, along with healthy snacks. A childs
serving size is about one tablespoon for each year of age. Each day
your child needs.
6 or more serving of bread, cereal, rice or pasta.
3 or more serving of vegetables
2 or more serving of fruits
3 to 4 serving of milk, yogurt, or cheese
2 to 3 serving of meat, poultry, fish, dry beans, and eggs
As a parent you should:
Provide a variety of health foods. Avoid foods that children
can choke on such as nuts, grapes, carrots, and round candies.
Serve meals and snacks at about the same time each day.
Keep meal times pleasant.
Teach good table manners.
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Let your child decide how much he will eat.

Dont use rewards to get your child to eat.
Do not use food as a reward.
Do not hold back food to punish your child.
Do not force your child to eat a new food.
Many children are afraid to eat new foods. To help your child
try new foods.
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Immunization is one of the most cost effective means of preventing

infectious diseases in children. It was the widespread use of vaccines
that led to the global eradication of smallpox and the elimination
of poliomyelitis from the western world. Over eleven antigens are
being used today for routine immunization of infants and children
all over the world which include diphtheria, pertussis, tetanus
toxoid, BCG, oral polio vaccine, measles, mumps, rubella, Hib and
hepatitis-B vaccine.
WHO has launched an expanded program of immunization to
prevent six diseases which are the major causes of morbidity and
mortality in children, all over the world especially the developing
world.
Schedule of vaccination under expanded program of immunization (EPI).
Age
Vaccine
Birth
6 weeks
10 weeks
14 weeks
9 months
BCG, OPV
DPT, OPV
DPT, OPV
DPT, OPV
Measles
Revised National Immunization program of India.

Beneficiaries
Ages
Vaccines
Infants
At birth
6 weeks
10 weeks
14 weeks
9 months
BCG, OPV
DPT, OPV
DPT, OPV
DPT, OPV
Measles
Contd...
Immunization
Contd...
Beneficiaries
Ages
Vaccines
Children
15-18 months
Pregnant women
4 - 5 years
10 years
15 years
16-36 weeks
MMR
1st booster dose of DPT, OPV
DT
TT
TT
TT two doses 4 weeks apart
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Development: Physical
and Mental
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The average age, when most children are doing one thing or another
is discussed in this chapter. Each child is different; if your child is
not doing any activity at the age listed, there is no need to worry.
You should wait for sometime, keep a watch on the child and you
may find the activity appears after sometime as there is a wide
normal variation. But if your child is late in doing several activities,
you should consult your doctor. Children born early need extra
time to catch up. For example a 2 month-old baby who was born
one month early can be compared to a 1 month-old time baby.
Catching up goes on until about the age of 2 years.
Growth of Body and Mind
Tip: Love, hold and talk with your baby from birth through
childhood. Read stories and play soft music often.
1 Month
Moves arms and legs at the same time.

Raises head when lying on tummy.
Jumps at loud noises or sudden movements.
Watches your face when its close.
2 Months
Turns head from side to side when lying on tummy.

Watches and follows briefly with eyes.
Smiles when talked to.
Coos: may have different cries.
3 Months
Holds head up.
Lifts head and chest when lying on tummy.
Development: Physical and Mental

Holds hands together.
Squeals.
4 Months
Rolls from back to tummy.

Follows objects with eyes.
Grasps objectsplays with hands.
Turns head toward sound.
5 Months
Stretches out arms to be picked up.

Knows familiar faces and voices.
Reaches for objects.
Makes sounds to get attention.
6 Months
Raises body up on hands.

Sits with support; rolls over.
Begins finger feeding.
Copies sounds made by others; babbles and laughs.
7 Months
Moves object from one hand to the other.
Pats and smiles at image in mirror.
Knows parents and care givers.
8 Months
Sits well alone.
Stands for a short time holding on for support.
Creeps (pulling body with arms and leg kicks).
9 Months
Crawls (on hands and knees).

Picks up objects with thumb and finger.
Makes two same sounds like ba-ba or ga-ga.
Responds to name.
May cry with strangers.
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10 Months
Hits together two objects held in hands.

Plays pat-a-cake and peek-a-boo.
Knows simple words no, bye-bye.
Looks for hidden objects.
11 Months
Says ma-ma or da-da.

Walks holding onto the side of the crib or playpen.
Stands alone briefly.
Waves bye-bye.
12 Months
Stands alone well : walks with support.

Says two words besides ma-ma, da-da.
Feeds self with spoon or fingers.
Follows simple commands and copies others.
15 Months
Walks well: helps with dressing.

Gives and takes toys.
Says 5 to 15 single words.
Drinks from a cup held in both hands.
Listens to stories: points to pictures.
Stacks 2 blocks: scribbles with crayons.
18 Months
Walks upstairs with hand held.

Eats with spoon and fork.
Plays at pretend games.
Points to body parts.
Likes to play with other children.
2 Years
Runs: jumps: throws ball.
Puts on clothes: washes hands with help.
Says 50 words: uses 2 to 3 word sentences.
Development: Physical and Mental
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Calls self by name: asks for more.

Opens a door.
Remembers where objects are hidden.
Begins toilet training.
3 Years
Kicks ball: walks up stairs.

Stacks 8 blocks.
Uses 3 to 4 word sentences.
Knows full name and sex.
Dresses self except for buttons.
Toilet training in progress.
Plays in small groups.
4 Years
Hops and stands on one foot: catches a ball.

May have makebelieve friends.
Uses at least 6 word sentences: ask questions.
Washes hands and brushes teeth without help.
Copies a circle and a cross.
Toilet trained.
Can share, wait her turn.
5 Years
Skips: stands on one foot for 6 seconds.

Tells a simple story using full sentences.
Listens: follows simple directions.
Counts to 10; knows 4 colours and own age.
Copies a square: prints some letters and numbers.
Dental Health
A bottle should not be used as a pacifier or sleep aid.
Before the first tooth comes in, parents should clean the infants
gums twice a day with a clean cloth.
Parents should brush their childs teeth twice daily until school
age and then supervise brushing, use a small pea size amount
of fluoride tooth paste.
Follow your childs development, if any delay consult your Physician.
Social, Emotional and

Learning Skills
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You are the most important person in your childs life you are his
daily role model. Help him learn social and emotional skills.
Gain your childs trust by talking, listening and paying attention.
Meal time is a good time to talk to your children and find out
whats going on in their lives.
Limit TV viewing and watch TV with your child.
Be aware of what your child finds on the Internet.
Begin teaching no smoking early.
Teach him to get along with others. Help him learn to solve
problems by peaceful means and not fight.
Help your child with homework and visit with teachers often.
Tell your child that you love him, praise him often. His own
self-respect depends on you and others nurturing his self value.
You are your childs best role model set a good example.
Warning Signs for Suicide
1. Suicide threats or previous attempts.
2. Giving away prized possessions or making a will.
3. Personality or behavior changes:
Rejection of parents
Emotional state: guilt, anxiety, thoughts of being bad
Recent failure in school or brushes with the law
Loss of interest in usual activities.
Help Your Child to be

Physically Fit
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Your child needs daily physical activity through play and sports to
stay fit. Good exercise habits learned early can help your child; to
become an active and healthy adult, who are less likely to be
overweight or to have high blood pressure, heart disease and many
other diseases.
Physical Activity Tips
Have your child walk or ride a bike to school and/or to visit
friends when it is safe. When on a bike he must bear a bike
helmet.
Plan physical activities with family or friends.
Limit the time for watching TV/Internet to less than 2 hours
per day.
Should go to a playground, park, gym or swimming pool.
Get the child involved in sports and exercise programmes in
his school and cheer him on.
Parents should set a good example and must do regular physical
exercise.
Exercise should be fun.
Prevent Child Abuse

and Neglect
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Child abuse is a hidden, serious problem. It can happen in any

family. The scars, both physical and emotional, can last for a
lifetime. Children cant protect themselves. Anyone trusted with
the care of a child is responsible for his well being.
Never leave a child aloneat home, at a store, in a caranywhere. Always leave your child with a trusted care giver.
NEVER SHAKE A BABY OR CHILD!!!Their brain is very
easily hurt. Shaking causes brain damage, blindness and death.
Never hit your child! It makes your child afraid and angry and
teaches violence.
Discipline is important for the development of your child. It
helps a child learn respect and self-control. Discipline is NOT
punishment. Never burn, scald, slap, shake, poke, bite, cut or
hurt your child. It makes your child afraid and angry and teaches
violence.
Words can hit as hard as a fist. A child is not bad. But a behavior
may be. Talk in ways that shows your child, you love him, but
not what he is doing. Use every chance to build self worth. Never
talk down to, shame or reject your child.
Vitamins
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Vitamin B1 (Thiamine)
Important for health of nerves and muscles, including heart. Helps
prevent fatigue and irritability.
Sources in diet: Pork, whole dried beans and peas, sunflower seeds,
nuts.
Symptoms of deficiency: Beriberi (nerve changes, sometimes edema,
heart failure).
Symptoms of overdose: None known.
Daily allowance: 1.5 mg.
Vitamin B2 (Riboflavin)
As an antioxidant, riboflavin protects cells from oxidative damage.
Supports good vision and is needed for healthy hair, skin, and nails.
Necessary for normal cell growth.
Sources in diet: Liver and other organ meats, poultry, brewers yeast,
fish, dried peas, beans, nuts, sunflower seeds, cheese, eggs, yogurt,
milk, whole grains, green leafy vegetables, nori seaweed.
Symptoms of deficiency: Skin lesions.
Daily allowance: 1.7 mg.
Vitamin B3 (Niacin, Nicotinic Acid, Nicotinamide)
Important for healthy skin and digestive tract tissue. Stimulates
circulation.
100
Source in diet: Liver and other organ meats, veal, pork, poultry, fish,
nuts, brewers yeast, dried beans, dried fruit, green leafy vegetables,
whole grains, milk, eggs.
Symptoms of deficiency: Pellagra (sensitivity to light; fatigue; loss of
appetite; skin eruptions; sore and red tongue).
Symptoms of overdose: Flushing of face, neck and hands; liver
damage.
Daily allowance: 19 mg.
Vitamin B5 (Pantothenic Acid)
Pantothenic acid is an active part of coenzyme A (CoA), important
in energy production and utilization. It supports adrenal glands to
increase production of hormones to counteract stress. Important
for healthy skin and nerves.
Source in diet: Nuts, beans, seeds, dark green leafy vegetable,
poultry, dried fruit, milk. Highest source: Royal jelly (from honeybees).
Symptoms of deficiency: Fatigue, sleep disturbance, nausea.
Vitamin B6 (Pyridoxine)
Helps body protein to build body tissue and in metabolism of fat.
Facilitates release of glycogen from liver and muscles. Helps in red
blood cell production, fluid-balance regulation.
Sources in diet: Sunflower seeds, beans, poultry, liver, eggs, nuts,
green leafy vegetables, banana, dried fruit.
Symptoms of deficiency: Nervous and muscular disorders.
Symptoms of overdose: Unstable gait, numb feet, poor hand
coordination, abnormal brain function.
Vitamins
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Vitamin B12 (Cyanocobalamin)

Important in formation of red blood cells and building genetic
material. Stimulates growth in children. Helps functioning of
nervous system, and in metabolizing protein and fat in the body.
Source in diet: Animal protein foods including meat, fish, shellfish,
poultry, milk, yogurt and egg.
Symptoms of deficiency: Pernicious anaemia (weight loss, weakness,
pale skin), confusion, moodiness, memory loss, depression.
Daily allowance: 2 mcg.
Biotin
Energy metabolism.
Source in diet: Egg yolk, liver, sardine, whole soya flour.
Symptoms of deficiency: Dermatitis, depression, muscular pain.
Daily allowance: 30 to 100 mcg.
Folate (Folic Acid, Folicin)
Helps form red blood cells. Assists in breakdown and utilization
of protein. Essential during pregnancy for its importance in cell
division. In its active form (the so-called methyl-containing form)
folate stabilizes proteins, nucleic acids, and membranes of cell as
well as supports brain function.
Source in diet: Dark green leafy vegetable, nuts, beans, whole grain
products, fruit, fruit juices, liver, egg yolk.
Symptoms of deficiency: Anemia, gastrointestinal disturbances.
Symptoms of overdose: Masks vitamin B12 deficiency.
Vitamin C (Ascorbic Acid)
Essential for connective tissue found in skin, cartilage, bone, and
teeth. Helps heal wounds. Antioxidant. Stimulates immune system.
Aids in absorption of iron.
102
Source in diet: Citrus fruit, berry, melon, dark green vegetable,

cauliflower, tomato, green and red pepper, cabbage, and potato.
Symptoms of deficiency: Scurvy (bleeding gums, weakness), delayed
wound healing, impaired immune response.
Symptoms of overdose: Gastrointestinal upsets, confounded results
from certain lab tests.
Vitamin A (Retinol)
Tissue maintenance. Healthy skin, hair, and mucous membranes.
Helps us see in dim light. Essential for normal growth and
reproduction.
Source in diet: Liver; yellow fruits, orange, and dark green vegetables
and fruits (including carrots, broccoli, spinach, cantaloupe, sweet
potatoes); cheese; milk; fortified margarine.
Symptoms of deficiency: Night blindness: dry, scaling skin, poor
immune responses. Serum (blood) values of vitamin A should be
between 0.15 and 0.6 g/ml.
Symptoms of overdose: Damage to the liver, kidney, and bone;
headache; irritability; vomiting; hair loss; blurred vision; yellow
skin.
Daily allowance: 1,000 mcg (3,333 IU).
Vitamin D3 (Cholecalciferol)
Helps regulate calcium metabolism and bone calcification. Called
the sunshine vitamin because it is manufactured in human skin
when in contact with ultraviolet light. Winter time, clouds, and
smog reduce its production in the body.
Sources in diet: Fortified and full fat dairy products, tuna, salmon,
Cod liver oil.
Symptoms of deficiency: Rickets in children, bone softening in adults.
Symptoms of overdose: Gastrointestinal upset; cerebral, cardiovascular, and kidney damage; lethargy.
Vitamins
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Vitamin E (D-Alpha-Tocopherol)
Antioxidant to prevent cell membrane damage.
Sources in diet: Vegetable oils and their products, nuts, seeds, fish,
wheat germ, whole-grain products, green leafy vegetables.
Symptoms of deficiency: In human, diseases of the pancreas and liver
as well as various forms of chronic diarrhea, anemia.
Symptoms of overdose: Perhaps fatal in premature infants given
intravenous solution. There are no known symptoms of oral
overdose.
Daily allowance: 10 mg (alpha-tocopherol equivalents).
Vitamin K (Phylloquinone)
Necessary for normal blood clotting.
Sources in diet: Dark green leafy vegetable; cabbage, polar bear liver
(actually fatal amounts).
Symptoms of deficiency: Severe bleeding on injury; internal
hemorrhage.
Symptoms of overdose: Liver damage, anemia (from synthetic forms).
Daily allowance : 80 mcg.
Egg
It is fashionable to eat only egg whites nowadays because the yolk
contains some fat and the egg white does not. The yolk actually
contains as much protein as the egg white, as well as the majority
of the vitamins and minerals. If you feel the need to limit the fat in
your diet, you do so by eliminating other foods, not by throwing
away what is in many ways is the best part of the egg.
Caloric Value of
Common Foods
Food group
Milk and milk products
Buffalos milk : 1 cup
Buffalos milk skimmed : 1 cup
Cows milk : 1 cup
Cows milk skimmed : 1 cup
Milk condensed, sweetened : 1 tsf
Curdbuffalos milk : 1 cup
Cereal and cereal foods
Wheat chappati (15 gm flour)
Wheat parotha (60 gm flour and 2 tsf fat)
Rice milled, boiled 1 cup
Pulses
Bengal gram roasted100 gm
Chana dal, Urad dal, Mung dal, Masur dal,
Tur dal 1 cup cooked
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Calories
206
78
160
70
62
182
40
256
138
369
105
Egg, meet, poultry

Egg medium boiled : one
Egg medium fried : one
Egg medium with millet : one
77
120
120
Mutton soup 1 cup

Kidney fried 50 gm
Chicken boiled 100 gm
34
100
132
Contd...
Caloric Value of Common Foods
105
Contd...
Food group
Fish
Mackerel 100 gm
Prom fret fried 100 gm
Prawns 100 gm
Salmon 100 gm steamed
Calories
136
205
104
199
Fats and oils

Ghee 1 tsf
Butter 1 tsf
45
36
Vegetables
Cauliflower cooked : cup
Potato boiled : 1 medium
Spinach cooked : cup
15
83
23
Fruits
Apple : 1 medium
Banana : 1
Grapes : 22-24
Guava : 1 medium
Mango : 1
Orange : 1 medium
Papaya : 1/3 medium
Peach fresh : 1 medium
Pear : 1
Pineapple : 1 slice
Pomegranate : 100 gm
66
132
72
51
122
68
50
32
84
44
90
Dried fruits
Currants : cup
Raisins seedless : 1 tsf
268
27
Nuts
Almonds : 12-15
Cashew nuts : 6-8
Coconut, fresh : 1 piece
90
88
54
Contd...
106
Contd...
Food group
Calories
Coconut water : 1 glass

Ground nuts roasted : 1 tsf
46
86
Sugar, etc.
Glucose : 1 tsf
Honey : 1 tsf
Brown sugar : 1 tsf
Sugar granules : 1 tsf
45
64
56
20
CALORY CONSUMPTION
Activity
Sleeping
Sitting
Walking (3.5 mph)
Calisthenics
Swimming (basic)
Cycling (10 mph)
Jogging (5 mph)
Skiing (moderate to steep)
Running (7.5 mph).
Calories burned per hour

72
72-84
336-420
300-360
360
360-420
600
480-720
900
Nutrition in Pregnancy
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During pregnancy, the developing fetus is exclusively dependent

on the mother for nutrition. The total energy cost of pregnancy is
estimated to be approximately 80,000 kcal, which breaks down to
an additional 300 kcal per day above nonpregnant needs. The
energy requirement increases minimally in first trimester but then
increase remains constant until term. Additional energy is required
during the second trimester for expansion of maternal tissues,
increase in blood volume, growth of uterus and breasts and
accumulation in fat stores. Additional energy needs in the third
trimester reflects the growth of the fetus and placenta. Because of
these differences in energy needs over the course of a pregnancy,
WHO recommends that energy intake should be increased by 150
kcal/day during the first trimester and by 350 kcal/day during
second and third trimester of pregnancy.
The requirement for protein, vitamins and minerals substantially increase during pregnancy. Increased need for protein (68%),
folate (100%), calcium (50%) and iron (200 to 300%) deserve special
attention when counseling pregnant women. The increase in energy
needs is not large in comparison to requirement for other nutrients
during pregnancy. Consequently, the quality of the diet must be
very high during pregnancy.
Therefore, during pregnancy, it is important for you and your
developing baby to remain as healthy as possible. It is the quality
of your diet which is important, not the quantity. You dont need
to eat twice as much as normal people says. Your own appetite
should tell you, how much you need to eat and drink. What you
eat during pregnancy is going to nourish you and your baby. So it
is most important that you eat sensibly and have a healthy diet.
108
TABLE 26.1: Nutritional requirement of pregnant, lactating and menopausal women
Calories required for

Resting metabolic rate
Light activity
Carbohydrates (gm)
Fats (gm)
Protein (gm)
Minerals
1. Calcium (mg)
2. Iodine (mcg)
3. Iron (mg)
4. Magnesium (ma)
5. Phosphorus (mg)
6. Potassium (mg)
7. Sodium (mg)
Vitamins
Vitamin A (IU)
Vitamin B complex
Thiamine (mg)
Riboflavin (mg)
Pyridoxine (mg)
Cyanocobalamin (mcg)
Biotin (mcg)
Choline (mg)
Folic acid (mg)
Inositol (mg)
Niacin (mg)
Para-amino benzoic
acid (mg)
Pantothenic acid (mg)
Vitamin C (mg)
Vitamin D (IU)
Vitamin E (IU)
Vitamin K (mcg)
Trace minerals
Chromium (mg)
Copper (mg)
Fluorides (mg)
Manganese (mg)
Molybdenum (mg)
Selenium (mg)
Zinc (mg)
Pregnant
Lactating women
51 and over
+300
+500
1850
+20 gm
277
59
44
+30 gm
1200
1200
175
200
30-60
18+
450
450
1200
1200
Average daily intake 1875-5625 mg
Average daily intake 1875-5625 mg
800
150
10
300
800
5000
6000
4000
+0.4
+0.3
+0.6
4.0
150-300
500-900
0.8
100 mg
+2
+0.5
+0.5
+0.5
4.0
150-300
500-900
0.5
1000
+5
1.0
1.2
2.0
3.0
150-300
500-900
0.4
1000
13
No recommended daily allowance

5-10
5-10
80
100
400
400
15
15
70-140
70-140
5-10
60
200
12
70-140
0.05-0.2
2-3
1.5-4
2.5-5
0.15-0.5
0.05-0.2
20
0.05-0.2
2-3
1.5-4
2.5-5
0.15-0.5
0.05-0.2
15
0.05-0.2
2-3
1.5-4
2.5-5
0.15-0.5
0.05-0.2
25
Adapted from Gooharelt and Shils, Modern nutrition in Health and Disease,
(5th ed), p 263.
Nutrition in Pregnancy
109
TABLE 26.2: Daily food guide for pregnancy and lactation*

Food group
Number of servings
Nonpregnant Pregnant
Lactating
woman
woman
woman
1. Protein foods
Animal
Vegetable
2. Milk and milk products
3. Breads and cereals?
4. Fruits and vegetables
a. Vitamin C-rich fruits and vegetables
b. Dark green vegetables
c. Other fruits and vegetables
2
(1)
(1)
2
4
4
(1)
(1)
(2)
4
(2)
(2)
4
4
4
(1)
(1)
(2)
4
(2)
(2)
4-5
4
4
(1)
(1)
(2)
*The daily food guide meets the RDA for pregnancy for all nutrients except iron,
folacin and energy. Approximately 400 additional kcal are needed to meet energy
needs. Daily supplementation of 30-60 mg iron and 400-800 mcg folacin are
recommended during pregnancy. In addition to daily food guide, 2T (30 ml) of
fats and oils should be included each day.
One serving is 2 oz (60 gm)
Should include at least one serving of legumes.
? Whole-grain products should be emphasized to provide additional magnesium,
zinc, folacin and vitamin B6.
TABLE 26.3: Food allowances for pregnancy and lactation*
a. Milk, whole or low fat

b. Meat, fish, poultry
(liver once a week) cooked
c. Eggs
d. Vegetables, including
i. Dark green leafy or deep yellow
ii. Potato
iii. Other vegetables
e. Fruits including
i. Citrus
ii. Other fruits
f. Cereal, whole grain or enriched
g. Bread, whole grain or enriched
h. Butter or fortified margarine desserts,
cooking fats, sugar, sweets
*An iron supplement is usually prescribed.
Pregnant
woman
Pregnant
Lactating
Teenage girl woman
3-4 cups
4-5 cups
4-5 cups
4 oz
3-4/week
4 oz
3 -4/week
4 oz
3-4/week
cup
1 medium
-1 cup
cup
1 medium
-1 cup
cup
1 medium
-1 cup
1 serving
1 serving
1 serving
4 slices
To meet
calorie needs
1 serving
1 serving
1 serving
4 slices
To meet
calorie
needs
1 serving
1 serving
1 serving
4 slices
To meet
calorie
needs
110

Recipe No. 1
(Pregnant woman)
Breakfast
Snack
Lunch
Snack
Evening Meal
Snack
Grape fruit or glass of orange juice

High fiber cereal and milk
Whole meal toast + butter + marmalade
Tea/coffee
Plain biscuit
Glass of milk
Whole meal bread sandwich with cheese and tomato or tinned
fish or cold meat filing
Fresh fruit
Tea/coffee
Meat casserole
Boiled potatoes or rice
Broccoli and carrots
Yogurts
Fresh fruit
Plain biscuit or toast and butter
Tea/coffee
Recipe No. 2
(Pregnant woman)
Breakfast
Tea 1 cup with 1-2 teaspoons of sugar

Milk 200 ml (1 glass)
Bread slices (2 large) or porridge (1 bowl) or idli
(2 medium) or chapatti (2 medium)
Cheese 30 gm (1 cube)/egg: 1/sprouts 25 gm (1 bowl)
Mid morning
Buttermilk 1 glass or fruit 1 medium sized
Lunch
Fresh salad
Chapati 4 medium (80 gm) preferably made of wheat mixed
with Bengal gram 4:1 or wheat mixed with soya flour 4:1 or
Rice (80 gm) 4 karchi (preferably steamed with pulses or green
vegetable)
Pulse/gram (60 gm) 2 katori or meat or fish or chicken (90 gm)
Curds 125 gm (1 bowl)
Green vegetables 250 gm (2 bowls)
Cooking oil 10 gm (2 tsf)
Evening tea

Cheese sandwich (1 small) or poha (1 bowl) or upma
(1 bowl) or vada (1 large)
Dinner
Same as lunch
Bedtime
Fruit
1-2 servings anytime during the day
Common Illnesses
During First Five Years
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Abscess
Abscess is a collection of pus, and its formation represents bodys
defence mechanism. By separating infected pus from surrounding
healthy tissue, the spread of infection is prevented. A child with an
abscess my feel unwell and feverish, but other symptoms depend
on where the infection is, sometimes an abscess points to an area
where it can burst. If this occurs internally it results in further spread
of the infection, but when it bursts on the surface of the skin the
pus escapes and the condition spontaneously improves. To speed
up the healing of an abscess, it may require an incision to allow the
pus to drain out. Few cases may require antibiotics.
Adenoids
The adenoids are organs for prevention of infection of the upper
airways and they are positioned on either side of the air passages
behind the nose and throat. Their main function is to prevent
infection of the upper airways and in most children they do this
effectively. However, they can become enlarged and this can have
two effects. Firstly, they may block the nose so that the child
constantly has to breathe through the mouth. Secondly, they may
obstruct the Eustachian tubes, which connect the nasal passages to
the middle ears. If this occurs, fluid from the middle ear each side
cannot drain into the throat and this results in poor hearing and
frequent ear infection. Such cases may require adenoidectomy to
improve hearing and breathing.
Allergic Rhinitis
Allergic reaction of the lining of the nasal passages which causes a
blocked or runny nose and, sometimes, watery eyes and sneezing
112
is called allergic rhinitis. It can result from airborne pollens, house

dust mites, fur and certain foods. You can help a pollen sensitive
child in various ways. Keep him indoors with windows closed when
possible; close car windows, remove and wash his clothing and
wash his face when he comes in; wash his hair before bed time;
avoid grassy and weedy places; and give him wraparound
sunglasses to lessen the amount of pollen landing on his eyes. These
precautions are particularly helpful in the early evening and before,
during and after a thunderstorm, when the pollen count rises.
Eating a daily teaspoon of local honey for two or three months
before a childs expected allergic rhinitis may be helpful. This is
because the tiny amounts of pollens in the honey have an
immunizing effect. If necessary, skin-prick tests can help to
determine the allergen thats responsible. There are various
remedies, such as nosedrops, sprays and antihistamine tablets,
which can relieve nasal congestion. Other treatments include
bathing sore eyes and nostrils with 600 ml (1 pint) of water to which
a pinch of salt has been added. Adding garlic to food is said to
relieve a stuffy nose.
Allergy
Allergy is an excessive reaction of the body to substances in contact.
The reaction can be a rash, bowel disturbance, runny nose and
sneezing, or breathing difficulties. Many things can cause allergy
in susceptible children, including certain foods, pollens, dust,
animal fur, feathers and insect bites. The tendency to develop
allergy often runs in families. Drugs such as antihistamines and
corticosteroids may dampen an allergy reaction. Its also worth
giving foods or supplements that are rich in natural antihistamines
such as vitamin C and flavonoids.
Anaemia
The color of blood is red because of the presence of red pigment
(haemoglobin) in the blood cells. Anaemia occurs when the
haemoglobin concentration falls below its normal level. This may
be because the haemoglobin content of the red blood cells is low or
because the number of red cells is significantly reduced. Whatever
the cause of anaemia, the child looks pale, is tired and may become
breathless after exertion. The most common cause of anaemia is
Common Illnesses During First Five Years
113
insufficient iron in the diet. Iron is needed to produce haemoglobin

and it is present in meat, fish, eggs, peas, beans, nuts and green
vegetables. Eating foods containing vitamin C along with iron-rich
foods boosts the absorption of iron from the digestive tract. In
contrast, caffeine reduces iron absorption so it is best not to drink
tea, coffee or other drinks containing caffeine with meals or just
after them. Blood loss in certain rare diseases may also result in
anaemia.
Appendicitis
Inflammation of the small sack of the bowel known as appendices
is known as appendicitis. If the appendix becomes inflamed it
causes tummyache, which usually starts in the center of the tummy
and moves to the lower right hand side. The child may have a
temperature, vomit and lose his appetite. The pain tends to get
worse the longer it goes on. If your child has these symptoms, call
the doctor immediately. Treatment is an operation to remove the
appendix.
Asthma
Problem of breathing due to narrowing of the breathing tube of
the lung which transports air in and out the body is known as
asthma. This narrowing may occur as part of an allergic reaction
or can be triggered by a viral lung infection, stress, exercise, cigarette
smoke, fumes and extremes of temperature. Wheezing and asthma
often run in families and you frequently find that another member
of the family suffers from asthma, eczema or hay fever. The child
who has an asthmatic attack wheezes, breathes faster than normal
and may struggle to get air. He may also cough and even vomit.
There are a number of drugs, which may be used during an
asthmatic attack. Some of these are referred to as bronchodilators
and they relieve the narrowing or spasm in the airways and so
make breathing easier. They can be given as tablets or inhaled from
a spin haler or aerosol. A child who is wheezing often has little
interest in eating or drinking. It does not matter if he does not eat
for a few days, but you should make sure he takes fluids frequently
and in small amounts, as he may vomit if given a large drink. A
child who wheezes frequently may benefit from drugs, which
prevent the allergic reaction from occurring in the first place. These
114
drugs have to be taken regularly, even when the child is well. It

may be worth trying to identify which substances trigger off an
attack. The house-dust mite, pollen, some foods and animal feathers
or fur can produce wheezing in susceptible children. If house-dust
mites are responsible, keep a childs bedroom as dust-free as
possible, wash bedding at as high a temperature as possible and
consider replacing fitted carpets with hard flooring and washable
rugs, so the mites cant easily multiply. You can destroy housedust mite in soft toys by putting them in the freezer overnight or, if
washable, by laundering. One exciting but unproven therapy is
Buteyko breathing. This involves a child doing breathing exercises
that help prevent her hyperventilating (breathing rapidly and
deeply). People with asthma tend to hyperventilate between attacks.
Early studies suggest that some people can reduce the frequency
of their asthma attacks by learning to recognize and control
hyperventilation. This may be because hyperventilation makes a
person breathe out too much carbon dioxide. A low carbon dioxide
level reduces the amount of oxygen available to the bodys cells
which, in turn, makes the child breathe even faster. A healthy diet
may discourage asthma thats related to allergy or infection; try
giving your child oily fish (like salmon or herrings) three times a
week, as well as plenty of foods rich in magnesium, and vitamins
C and E. Adding garlic to meals may also be helpful. Wheezing
may start in the first year of life. At this stage it is impossible to say
whether or not the child is going to develop asthma. The majority
of children with asthma grow out of it during childhood and are
left with normal lungs.
Bed Wetting
Inability to remain dry in bed after the age of four and half years is
called wetting. It is slightly more common in boys than girls and
the tendency may run in families. As a child wets the bed without
knowing, it is a mistake to blame her for doing it. She is more likely
to grow out of it if she is treated kindly and praised when she does
have a dry night. It may be helpful to take her to empty her bladder
when you go to bed. In some cases children who have previously
been dry at night suddenly begin wetting again, perhaps due to
some upset in their life. Bed-wetting can also be caused by a urinary
infection or a medical condition such as diabetes. If the wetting is
due to an infection, the child experiences discomfort when she
115
urinates or may pass small amounts frequently. A child with

diabetes passes a lot of urine during the day as well as at night and
drinks more than usual. Consult a doctor if above mentioned
symptoms are present in your child.
Birthmarks
There are several kinds of birthmark, most of which disappear
during childhood without treatment. These include the stork
marka pink on the neck, forehead or eyelids and the Mongolian
blue spot-a bluish mark across the back, which is common in black
and Asian babies. A less common form of birthmark is the
strawberry mark. This red mark is raised and feels a little uneven,
but is not painful. Strawberry marks can occur anywhere on the
body. They are not usually present at birth but more commonly
appear during the first two months of life and gradually fade over
a period of months. Most strawberry marks have disappeared by
the time the child is five years old. Port-wine stains, unlike
strawberry marks, are permanent and present from birth, though
some can be helped by laser treatment.
Blood in Urine or Bowel Motions
If you notice blood in your childs urine or bowel motions, you
should consult doctor. The cause is probably a minor one, but it
could indicate a more serious condition.
Boils
A boil is a small abscess (collection of pus) in the skin, caused by a
bacterial infection. The boil may throb, but the child is not generally
unwell. Try to keep the childs skin, hands and nails clean to prevent
the spread of infection. Treatment is with antibiotics.
Bow Legs
In the age of toddlers finding of bowlegs is normal. Provided the
bowing is symmetrical (that is, the same amount on each side) it is
highly likely to resolve itself by the time the child is three or four.
Consult your doctor if bowing is persistent or unequal or severe.
116
Breath Holding
Like temper tantrum, breath holding spells are usually calls by
frustration. Attacks sometimes start towards the end of the first
year but they are more common in the second or third year. They
rarely occur in children over five. During an attack the child cries,
breathes in and fails to take another breath for some time. The
symptoms, which develop depend on the interval between breaths.
Initially the child goes blue and stiffens, and she may become
momentarily unconscious. Normal breathing usually starts again
spontaneouslythe child takes another breath and her color
gradually returns. If it does not, call a doctor at once. Breath holding
attacks are frightening for parents, particularly as there is little that
can be done once an attack has started. However, some parents
find that giving the child a shake or a light slap makes her take
another breath more quickly. Try to prevent an attack by avoiding
situations, which are likely to be frustrating for your child and
distract her when she looks as if she is about to start screaming,
although this is not always easy. It is also important for the child to
learn that these attacks do not mean that she gets what she wants,
or this will encourage her to behave in this way. Breath holding
attacks gradually disappear with growing age.
Bronchiolitis
Viral infection of the small breathing tubes of the lungs is called
bronchiolitis. It usually occurs in children under two and is most
common in the first year of life. At the beginning of the illness the
child may have symptoms of a cold (a runny nose and sneezing),
but as the infection moves down to the lungs she develops other
symptoms such as coughing, wheezing and rapid breathing. She
may also have difficulty getting her breath (particularly when
feeding) and her lips may turn blue when she coughs. Unfortunately, there is no treatment for bronchiolitis, although sometimes
antibiotics can prevent secondary infection. Bronchiolitis gets better
by itself in a week or so. Babies with bronchiolitis can develop
feeding problems and quite severe breathing difficulties. If you
notice these symptoms it is essential to consult the doctor; he may
suggest that the baby goes into hospital for observation and
treatment.
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Bronchitis
Infection of the large breathing tubes of the lung is called bronchitis.
The child with bronchitis has a cough and fever. She may also be
breathing faster than usual and wheezing. If your child shows these
symptoms, consult the doctor at once. Antibiotics are sometimes
used to prevent the development of secondary bacterial infection
in bronchitis. Some children find cough mixtures soothing and
occasionally an anti-wheeze drug from the doctor may help. A child
with bronchitis may lose her appetite, but it is important to see
that she has plenty to drink. There is no permanent damage to the
lungs and the condition gets better over a few days.
Bruises
Leaking of blood under the skin produces bruises. They are usually
caused by a knock or fall and will gradually disappear without
treatment. Problems of clotting mechanism may result in excessive
bruising and requires doctors opinion.
Chickenpox
Chickenpox is a viral infection characterized by little blisters, which
appear in crops on the body first, then the face and scalp and finally
the limbs. The spots are itchy and easily broken, forming crusts or
scabs. When the rash begins, the child often has a fever, which
may last for three to four days. Paracetamol elixir is helpful to
reduce the temperature. There is no specific treatment; just keep
the child as comfortable as possible and try to stop him from
scratching the spots because this can lead to secondary infection
and scarring. The itching can be reduced by dabbing the rash with
calamine lotion. Baring a few most of the scars disappear with time.
Phimosis and Circumcision
Surgical removal of front part of the foreskin of the penis is called
circumcision. It is usually performed for religious and social
reasons, rather than medical ones. In a baby the foreskin is fused to
the tip of the penis and cannot be pulled back. As the penis grows
during infancy, the foreskin gradually separates from the glans so
that it can be drawn back in many boys by early childhood. If the
child has a very tight foreskin or suffers repeated infections
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underneath the foreskin, such as balanitis then circumcision may

be recommended.
Cleft Palate
A cleft palate is an abnormality, which is present at birth. The palate
makes up the roof of the mouth and separates the mouth from the
nasal passages. When it is cleft there is a central gap in the part of
the palate that lies at the back of the mouth. An untreated cleft
palate causes feeding difficulties and speech problems. Surgical
correction is done at the age of ten months.
Clubfoot
Developmental abnormalities while the baby is still in the womb
may result in congenital disorder of the skeleton producing
clubfoot. Newborn baby will undergo some simple routine tests
when it is born, one of which will be checking the feet to discover
any abnormal twisting which would indicate a clubfoot. One or
both feet may be affected and the signs will be a foot bent either
downwards and inwards or upwards and outwards. Either way
the foot will look twisted and the sole will face in or out rather than
down. The feet of a newborn baby some times look turned in like
clubfeet but in most cases wont be. If the foot can be pushed gently
forward so that the little toe almost touches the shin, the baby does
not have a clubfoot. A clubfoot is always correctable. If the defect
is only slight, you will be shown by the doctor how to manipulate
the foot gently every day until it has gone back to a normal position.
If it is more severe the foot might be bound or put in a plaster cast
in addition to manipulation in order to stop the foot growing back
to its former position. Rarely surgical correction may be required
in very severe cases.
Coeliac Disease
Manifestations of coeliac disease results from damage of the small
intestine lining due to sensitivity to a type of food. It results from
eating foods containing gluten, a protein found in wheat, rye, barley
and oats. When the child eats these foods, he produces antibodies
to protect his intestine from gluten. These gluten antibodies circulate
in the blood and may damage the bowel, and so preventing food
from being absorbed properly. Children with celiac disease fail to
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thrive, develop diarrhoea and may suffer from anaemia and vitamin
and mineral deficiencies. The condition only develops after the child
has been exposed to foods containing gluten. If a child with celiac
disease avoids all foods, which contain gluten, the symptoms
disappear and the damaged bowel returns to normal, but the special
gluten free diet must be followed throughout life. Gluten sensitivity
can also be associated with many other disorders, including blisters,
mouth ulcers, pitted and discolored tooth enamel, diabetes,
convulsions, fatigue, depression and, in adults, fertility problems.
Raised levels of gluten antibodies are more common in people with
insulin dependent diabetes, thyroid gland inflammation, and
Downs syndrome. Some children suffer from one or more gluten
sensitivity disorders but have no signs of bowel damage.
Confirmatory diagnosis requires positive endomysial antibody test
followed by a biopsy of the small intestine.
Cold
Viral infection of the nose and throat can produce runny or blocked
nose, cough, sore throat and fever. Young children with colds often
go off their food for a few days. Antibiotics dont help, but vitamin
C may speed recovery. Paracetamol elixir can reduce a high
temperature and ease a sore throat. In young babies a blocked nose
can make feeding difficult, which may require nose drops.
Cold Sore
Blisters on and around the mouth is the typical presentation of cold
sore. The blister, which may be painful, bursts, crusts over and
heals without treatment within ten days and without a scar. Stress
like cold or chest infection, exposure to strong sunlight can result
in recurrence of cold sore since, it is caused by herpes simplex virus.
Colic
Tummy ache occurring in spasms is known as colic. Infantile colic
makes a baby draw up his knees and cry. It may occur a number of
times a day, but in between the baby appears well. This type of
colic, which occurs in both bottle and breast-fed babies, can be quite
trouble some for the first three months of life or longer, especially
in the evening. It may help to give the baby plenty of time at the
breast and in your arms when he finishes feeding. The habit of
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eating little and frequently may be helpful for breastfeeding mother.

Color Blindness
Color blindness is not uncommon in boys but is quite rare in girls.
A color blind child has difficulty distinguishing reds and greens.
This is often only discovered when a child is tested with special
color charts. It may run in families and there is no treatment to
counteract it.
Congenital Dislocated Hip
The hip joint works like a ball and socket, the top of the leg bone
being the ball and part of the pelvis (hip bone) being the socket. In
some babies the socket is rather shallow and allows the leg bone to
slip in and out. Although this is not noticeable at birth, a doctor
can feel whether the hip joint easily dislocates when he examines
the baby. It is more common for the doctor to feel a click as he
moves the hip (a Clicking hip), without it actually slipping out of
the socket. In this case all that is usually required is for the baby to
be checked again several times to make sure the joint becomes
completely stable over the first few months of life. Some doctors
suggest using two terry toweling nappy squares during these early
weeks to stabilize the leg bone in the socket. It is unusual for a
simple clicking hip to need more treatment than this. If the babys
hip does dislocate, then it will need an early visit to a bone specialist
so that the hip can be placed in the best position for normal
development. This may involve the baby wearing special splints
and, very occasionally, a plaster or an operation may be necessary.
Arthritis and limp can develop in untreated cases.
Conjunctivitis
Inflammation of the outer surface of the front eyeball and the inner
lining of the eyelids is called conjunctivitis. It makes the white part
of the eye appear red. Sometimes there is a yellowish discharge
and the eye feels itchy. The causes include infection, allergy to
pollen, or a foreign body in the eye. It is usual for both eyes to
become inflamed with infection or allergy, but when conjunctivitis
is caused by a foreign body only one eye is affected. The first thing
to do is wipe away any discharge with some cotton wool moistened
in clean water. Antibiotics may be required in case of bacterial
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infection or if abrasion has occurred. Antibiotic creams should be

applied, with clean hands, by pulling down the lower lid and
placing a little cream on the eye. When the child blinks, the cream
will be spread over the affected area. Allergic conjunctivitis may
require anti allergic eyedrops. If a child is suffering from infectious
conjunctivitis, be careful to keep his towel and face flannel separate
from those of the rest of the family and keep the eye clean by
washing it regularly with warm water. A mild form of conjunctivitis, called sticky eye, is common in babies. This is frequently
made worse because a babys tear ducts are too small to drain the
eye properly. The babys eye should be bathed regularly with clean
water and cotton wool (using a separate piece of cotton wool for
each eye). Antibiotic drops may also be required.
Constipation
A baby with bowel motions that is hard and difficult to expel is
said to constipate. If your child passes motions of soft or firm
consistency infrequently and without straining unduly, he is not
constipated. If, on the other hand, the motions are hard, passed
with difficulty and occasionally blood streaked, he is likely to be
constipated. Blood streaking comes from little tears caused by the
passage of hard motions through the anus. In the vast majority of
children constipation is a temporary problem, which can be
resolved by changes in the diet. A young child can be given more
water or a little prune juice on a spoon. An older childs diet should
contain more fruit, vegetables and wholegrain cereals to increase
the fibre content. Some children become constipated because they
put off going to the lavatory. This can happen when a child is away
from home (perhaps on holiday) and feels anxious or takes a dislike
to a strange lavatory. Encourage the child to go at set times every
day is also helpful.
Convulsions
Convulsions are caused due to abnormal bursts of electrical
activities in the brain. A convulsing child may have jerking limbs,
become pale, be unresponsive or unconscious, and wet and soil
himself. The vast majority of convulsions stop spontaneously after
some minutes, but they can be frightening. There are many causes,
but by far the most common are convulsions brought on by a high
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fever. These are known as febrile convulsions and occur in one in

twenty normal healthy children between the ages of six months
and five years. It is the raised temperature, often upto 40C (104F),
which sets off the abnormal activity in the brain, so that the
convulsion may occur at the beginning of an illness before the
parents realize that the child is unwell. Infections of the ear, nose
and throat are often responsible. If a child has a convulsion consult
your doctor at once. Once your child has had one febrile convulsion
he is likely to have another, so you need to be aware of his temperature when he is unwell. If he becomes feverish keep him cool,
give him paracetamol elixir to reduce the temperature and call your
doctor. The doctor may advise regular anticonvulsant drugs for
children who have repeated febrile convulsions, but medical
opinion is divided about this. Simple febrile convulsions do not
cause brain damage and children grow out of them by the time
they are four or five years old. Much less common are convulsions
caused by a brain infection, a low sugar or calcium level in the
blood, or certain rare inherited diseases. Other triggers include brain
damage before, during or after birth; exposure to flashing lights
(such as strobing lights in a cinema); and food sensitivity. Idiopathic
epilepsy means convulsions without an apparent reason and
requires regular anticonvulsant therapy for prolong period.
Cough
Inflammation or irritation in the lung or the throat is countered by
the body by a mechanism called coughing. The action forces air
out of the lungs at high pressure and so expels any mucus, secretions
or inhaled foreign body from the breathing tubes. Coughs often
occur with colds as part of a viral infection of the upper airways
and throat. In this situation no special treatment is needed. A cough
is sometimes the result of an infection in the lungs, such as
bronchiolitis, bronchitis or pneumonia. It may also occur with
asthma or following accidental inhalation of dust or a foreign body
such as a peanut. These require antibiotics and other appropriate
treatments.
Cradle Cap
Greasy yellow scales and crusting on a babys scalp is called Cradle
cap. Sometimes there are also patches of dry red itchy skin over
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the face, body and nappy area. This is a form of eczema known as
seborrhoeic dermatitis. The scales on the scalp can be removed by
daily shampooing and gentle combing after they have been
moistened overnight with an oily preparation such as olive oil.
Patches on the face or body usually clear up on their own.
Croup
Barking cough and noisy breathing with or without fever is called
croup. Croup is usually caused by an infection in the voice box.
Other causes include an inhaled foreign body, allergy and even
excitement or upset. More usual in winter, it is most common in
toddlers. The symptoms can develop quite suddenly and can be
frightening. Moistened air may help the condition and this can be
provided in the home by taking the child into a steamy bathroom
or by boiling a kettle in the room. However, medical advice must
be seeked.
Cyanosis
Blue appearance of the lips, fingers and toes is known as cyanosis.
The blueness is caused by reduced amounts of oxygen in the blood
and tissues and occurs with some diseases of the heart and lungs.
If cyanosis develops, call your doctor urgently or take the child
straight to a hospital. Sometimes a childs hands and feet go blue
when they get too cold, but this is not serious and normal color
returns with warming. Breath holding spells may also produce
cyanosis but another breath restores normal color.
Cystic Fibrosis
Cystic fibrosis is an inherited disease and causes repeated lung
infections and difficulties with absorbing nutrients from food.
Although both the parents of a child with cystic fibrosis are
physically healthy, they each carry the abnormal cystic fibrosis gene
and have a one in four chance of producing an affected child in
each pregnancy. Researchers can now identify people who carry
the cystic fibrosis gene and they can also use chorionic villus
sampling to identify affected babies. The condition is usually
diagnosed when a child fails to thrive or has recurrent chest
infections. Helping measures include diet attention, physiotherapy
and regular medical treatment.
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Dandruff
Excessive scaling of dead skin, usually on the scalp or on the
eyebrows is called dandruff. Dandruff appears as small whitish
scales of skin, which come loose when the hair is brushed or
combed. The scaling is sometimes accompanied by itching, which
may be intense at times. In severe cases, the skin and hair become
excessively greasy, patches of scalp redden, and a fluid oozes from
tiny openings that appear, forming hard, yellow crusts. The skin
on the face, especially on the forehead, cheeks and eyebrows,
becomes reddened, and scaling occurs in the skin of the ears and
on the front of the chest, over the breast and collar bone. Occasionally, dandruff may be associated with other skin conditions,
such as eczema and impetigo, or an infection of the outer ear canal.
Contrary to popular belief, dandruff is not an infection. It is part of
a condition that doctors call a seborrhoeic tendencyan over
production of sebum, the oil secreted by glands in the skin.
However, recently it has become clear that some cases of dandruff
are linked with a micro-organism called pityrosporum. An
antifungal shampoo called ketoconazole is available on prescription
from your doctor. The shampoo kills the pityrosporum and can
often make a significant improvement to the dandruff. There is no
cure for dandruff, which may disappear for good at any age, or
disappear for a while and then return for no apparent reason.
However, regular washing with baby shampoo may treat the
condition. Avoid excessive shampooing or massaging of your
childs scalp as this may over stimulate the skin and make the
condition worse. Some medicated and antidandruff shampoos are
suitable for young children and may be used occasionally.
However, others are not and could make the dandruff worse. Only
severe cases of dandruff require medical treatment. Consult a doctor
if your child has severe flaking, itching and cracking of the scalp,
or if there is also hair loss.
Dental Decay
A sticky layer called plaque coates the teeth after eating. Bacteria
break down sugar in plaque and produces acid which eats into
enamel and encourages decay. Some children are less prone to
decay, perhaps because they form less plaque, have different
bacteria, more resistant enamel, a better diet or take in more
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fluoride. Once decay reaches the tooths nerve, the child has
toothache. Help to prevent dental decay by reducing the amount
of added sugar in your childs diet and by brushing the teeth with
fluoride toothpaste. Never let your baby go to sleep while drinking
a bottle of milk or juice because the resulting pool of liquid round
a sleeping babys front teeth does not get washed away by saliva
as it does when she is awake.
Diabetes
Insulin controls the sugar level in the blood and tissues and its
deficiency because of insufficient production by the pancreas results
in childhood diabetes. This results in a high blood sugar level, which
makes the child feel thirsty, drink excessively and pass a lot of urine.
The child may also lose weight and feel unwell. Treatment with
insulin injections daily enables to blood sugar level to return to
normal, while a special diet and regular monitoring of the amount
of sugar in the urine or blood can help to control the condition.
Diarrhea
Frequent passing of loose watery motions is called diarrhoea. In
childhood it usually occurs with gastroenteritis, an infection of the
bowel. Dehydration will happen if the child is losing more fluid in
the diarrhoea than the intake. You should therefore give plenty of
fluids, especially to young babies, who become dehydrated very
easily. Its best to give small amounts of fluid frequently. If you are
breastfeeding, continue but give more feeds than usual and drink
plenty yourself. A bottle fed baby can have extra fluids as boiled
water. Suggestions for older children, including babies on a mixed
diet, include water, weak tea, or thin vegetable soup. Oral rehydration salts may be recommended. Alternatively, prepare a homemade oral rehydration mixture by adding one level teaspoons of
sugar in a glass of water. Both shop-bought and home-made oral
rehydration mixtures provide energy in the form of sugar, as well
as replacing minerals lost in the diarrhoea, and correcting the acidity
balance in the childs body. Less acute forms of diarrhea may result
from sensitivity to certain foods, respiratory infection, anxiety and
other problems of the bowel. In such cases the child does not usually
become ill suddenly, but may fail to gain weight in the normal
way. Contact your doctor without delay if your child cant keep
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fluids down; has diarrhoea severely for twelve hours, or mildly for
twenty-four hours; or has repeated vomiting, or blood in the faces.
Easily digested foods for a child recovering include stewed apples,
ripe bananas and brown rice. Restoration of normal population of
helpful bowel bacteria can be achieved by giving live yogurt or
commercially available preparations.
Diphtheria
Diphtheria is a serious and highly infectious bacterial disease, which
causes inflammation of the nose and throat. This inflammation may
become so severe that it interferes with the childs breathing. Every
child should be protected against diphtheria by immunization,
which is part of the triple vaccine (tetanus, whooping cough and
diphtheria) given in the first few months of life.
Dyslexia
Difficulty in reading or learning to read is known as dyslexia, which
may be accompanied by spelling and writing problems. Affected
children do not show back wardness in other school subjects and
many of them are of average or above average intelligence dyslexic
children usually benefit from extra specialized help with reading
and spelling. Use of precisely tinted lenses has been shown to be
very helpful in recent research.
Earache
Inflammation of the external ear canal is called otitis externa. It is
caused by a bacterial, viral or fungal infection. The inflammation
causes pain or itchiness in the ear canal and sometimes a discharge.
Appropriate anti-infective agents may be required for the treatment.
It is important that the ear canal is kept dry until the infection clears,
so take care when washing the childs hair and do not allow him to
swim. Inflammation of the middle ear is called otitis media. The
illness can be caused by a bacterial infection and may be accompanied by a cold or tonsillitis. The child is usually unwell and
feverish and may complain of earache or headache; he may also be
slightly deaf. As the inflammation progresses the middle ear fills
with fluid and this causes the pain and deafness to worsen.
Sometimes the only indication of infection in a young child is that
he repeatedly pulls or rubs his ear. If your child has any of these
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symptoms, consult your doctor. Treatment may include giving

paracetamol elixir to relieve pain and fever, nasal decongestants
to assist drainage of the middle ear, and antibiotics to clear the
infection. Sometimes the eardrum ruptures with the pressure of
fluid, which relieves the pain and produces a discharge from the
ear. Consult your doctor if this happens. Repeated attacks of otitis
media may require removal of the adenoid glands and insertion of
grommets (tiny plastic tubes) in the eardrums to help drain the
infected material from the ear.
Eczema
Disease of the skin characterized by red itchy rashes is called
eczema. The most common type is atopic eczema. Often there is a
family history of asthma, eczema or hay fever. Eczema may start
in the first four months of life affecting the body and face. As the
child gets older it tends to involve the elbow, the knee and the
wrists and ankles. Sufferers should avoid wearing tight-fitting,
rough-fibered garments loose, cotton clothing is best. Treatment
includes emollients, moisturizing creams and bath oils. Eczema is
sometimes worsened by food sensitivity, so triple elimination and
challenge diet may be recommended. House dust mite droppings
are another possible trigger. Contact (allergic or irritant) eczema is
also common and is often provoked by prolonged or repeated
contact with various substances, including bubble bath, saliva
(leading to a rash cased by excessive dribbling), orange juice,
detergent, sap, nickel and a wet or dirty nappy; by ointments or
sprays containing neomycin, antihistamines or local anesthetics;
and by skin infections such as ringworm and impetigo.
Fever
Body temperature more than normal (98 to 99F) is known as fever.
The temperature often has an obvious cause, such as a cold, but it
may be advisable to have a feverish child examined by a doctor. A
high temperature is not usually harmful, though in some young
children it causes febrile convulsions. A feverish child is more
comfortable if she is cooled down. This can be done by giving her
paracetamol elixir in the correct dose. During fever the child should
be made to drink plenty of water but should not be forced to eat if
he is not willing to.
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Fifth Disease
(Slapped Cheek Disease or Erythema Infectiosum)
It is a viral disease characterized by fever and rash that may last
for ten days. Its incubation period is about sixteen days. The cheeks
look as if they have been slapped, and there may also be a blotchy
rash on the forearms, lower legs and slightly on the trunk. The
rash may itch and it feels worse when the skin is hot. Other
symptoms can include a cold, sore throat, headache and diarrhoea.
Calamine lotion and paracetamol can be helpful but no specific
treatment exists.
Flat Feet
In comparison to adult, infants and young children have fatter,
wider and flatter feet. In young children fatty pads create a fullness
on the undersurface of the foot so that the arch is not visible. This is
quite normal. As the child grows older this fatty pad will disappear
and the arch is revealed. Childs feet hurting during exercise
requires doctors opinion.
Food Sensitivity
A wide variety of symptoms, including flushing, tummy ache,
diarrhoea, vomiting, wind, joint pain, rash, headache, fatigue,
weakness, palpitations, cough, runny nose, convulsions, depression,
nerve disorder, blister, mouth ulcers and pitted and discolored teeth
can be produced by food sensitivity. Factors encouraging it include
a family history of any allergy, bottle feeding, a missing digestive
enzyme, gastroenteritis, repeated antibiotics, and a poor diet. There
are four main types. The first is a non-allergic immune reaction,
which often result from a common food such as wheat, milk and
yeast, and many other foods can act as triggers. This may alter the
level of an antibody called IgG and perhaps IgE too, but it isnt
actually allergic. Non-allergic immune reactions begin within
seventy two hours of eating the foods. The symptoms tend to be
vague. One explanation for this reaction is the leaky gut
phenomenon, in which some sort of damage to the intestinal lining
allows poorly digested food particles to pass into the bloodstream
and trigger an immune reaction. The second type of food sensitivity
involves a reaction to a toxin (for example, from food poisoning
bacteria), an additive (such as tartrazine, the flavor-enhancer
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monosodium glutamate, or MSG, the sweetener aspartame), or a

pharmacologically active substance (such as caffeine). The third
type results from a missing digestive enzyme such as lactase, the
enzyme that digests milk sugar (lactose). The fourth is a true food
allergy, and is associated with a raised level of IgE antibodies. It
begins within two hours, of eating a tiny amount of a food such as
eggs, fish, shellfish, wheat, milk, nuts, nut oils, seeds and
strawberries. Usually only one or at the most two foods act as
triggers. Food allergy may cause urticaria, asthma, allergic rhinitis,
migraine, vomiting, diarrhoea, swollen lips, tongue and throat,
wheezing, chest pain, fainting and severe shock. A severe reaction
(anaphylaxis) requires urgent treatment with an injection of
adrenaline. The best treatment for most food sensitivities is to use
a food diary to discover the culprit and either avoid it or, eat
smaller amounts, or eat it less frequently. The best way of
identifying food sensitivity is with a triple elimination and challenge
diet. However, because this often involves eliminating a basic food,
its advisable to have a doctors or dietitians help so you can still
provide your child with essential nutrients. The diet involves
eliminating the suspect food for three weeks. If the symptoms settle,
challenge your suspicion by offering the food again. If the symptoms
then reappear, eliminate the food for a week, then do a second
challenge; if they return, only to disappear when you next eliminate
the food and come back with the third challenge, you can be
reasonably sure you have correctly identified the culprit.
Identification of food allergy, requires skin-prick and blood tests.
Such tests are unhelpful for non-allergic immune reactions.
Gastroenteritis
Diarrhoea due to viral or bacterial infection is known as
gastroenteritis and is usually accompanied by vomiting. The child
may be generally unwell with a tummy ache and fever, so consult
your doctor about treatment. It is most important to give him plenty
to drink to prevent him from becoming dehydrated. Gastroenteritis
usually clears up after a few days, but dehydration may require
proper rehydration treatment. Because, breast milk contains
protective antibodies, so breast-fed babies suffer less from
gastroenteritis.
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Glue Ear
Sound waves may be prevented from reaching the inner ear if the
middle ear is filled with glue like fluid in condition known as glue
ear. There is no pain or fever, but the childs hearing is impaired.
Glue ear affects one or both ears and usually follows an infection
of the middle ear (otitis media) in association with a blocked
Eustachian tube. This blockage is often caused by enlarged
adenoids. Treatment includes antibiotics and nasal decongestants,
but if these fail an operation may be necessary. The adenoids are
removed and the glue is sucked out through a slit made in the
eardrum. A tiny plastic tube called a grommet is inserted into the
slit to allow air to pass into the middle ear and the fluid to drain
out. In a few months eardrum heals and the grommet falls out on
its own. Precaution should be taken to keep the ear dry till the
grommet remains in place.
Growing Pains
Pain in the legs or arms is a common childhood complains. In spite
of being otherwise well the pain may make the child sleepless. The
cause is unknown but may relate to swelling of the muscles after
strenuous exercise. Whatever the cause, growing pains are not
serious and disappear in time. Massaging the limbs and putting a
warm hot water bottle on or near them may ease the pain. Consult
your doctor if pain is persistent or is associated with problems.
Hare or Cleft Lip
It is a congenital abnormality in which normal continuity of the lip
is breached. It can vary from a small notch in the upper lip to a
complete cleft that extends into the nostril. Treatment is surgical
correction around 10-12 weeks age.
Headache
Headache during childhood can be due to variety of reasons like
pain the tooth, ear or fever. Treatment for the complaint itself
normally relieves the headache. Recurrent headaches, when the
child is well in between, may have an emotional basis or may be
migraine, and you should consult your doctor. A headache in
conjunction with a temperature, vomiting, drowsiness and
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reluctance to look at the light may indicate more serious disease,

such as meningitis and requires urgent medical attention.
Head Banging
Repetitive head movements like head banging, rolling and rocking
are common occurrences during the course of childs development.
Head rolling and rocking may be seen in the second six months of
life. The baby rolls her head from side to side and may rock when
she is put down in her cot. Some children find these movements
comforting and generally stop after a while or rock themselves to
sleep. A child between the ages of one and two may bang her head
on the side of the cot, wall or floor. This can be due to a temper
tantrum or to seek attention. Kind and firm handling may help
prevent these episodes, but if they do occur the child should be
protected from damaging itself, though it is rare for children to do
themselves any actual injury. Consult your doctor if head banging
is frequent and persistent.
Head Lice
Head lice is a common childhood problems, and their presence
has got nothing to do with hygiene. The lice cause the child to
scratch her scalp and this can lead to skin infection if left untreated.
A safe, effective treatment is to wash hair, load it with conditioner,
comb it with a wide toothed comb, then remove the lice with a
fine-toothed comb. Dunk the comb into a bowl of water after each
combing to drown the lice. This removes only the adult lice, not
the nits, which remain stuck to the hairs. Some of these nits contain
immature lice. However, if you repeat the treatment twice a week
for two weeks, youll catch the newly hatched lice from these nits
too before they can lay more eggs. Close examination and treatment
of other family members and close contacts is also important
because head lice resides and lays eggs on the hair and from their
they can be transferred to others.
Heart Murmur
Disturbance in the blood flow during passage through heart
produces noises that can be heard with a stethoscope, and are
known as murmur. The disturbance can be caused by a structural
abnormality of the heart, as in congenital heart disease, or may just
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relate to the actual flow of blood itself. Sometimes, harmless

murmur may be heard in a healthy baby with healthy heart. This is
produced by the flow of blood and vanish with age without any
harm.
Hyperactivity
A child is said to be hyperactive if he suffers from excessive activity
in combination with inability to settle. Their behavior often appears
impulsive and restless, they have poor concentration and are easily
distracted. A hyperactive child may be unable to concentrate at
school, resulting in serious setbacks to learning. A small proportion
of hyperactive children are mentally retarded, but the majority of
them are otherwise well. The cause of hyperactive behavior remains
uncertain, but sensitivity to certain foods and food additives may
play a part in some cases. If your child shows signs of being
hyperactive, consult your doctor. Whatever the cause, hyperactive
children benefit from consistent, firm and kind handling within an
orderly environment without too many distractions. The condition
usually improves with age. However, many children never appear
to tire and are always very very active. These are normal children.
Impetigo
It is a bacterial skin infection, which usually begins on the face but
can occur anywhere on the body. It starts with red spots, which
rapidly become little blisters and then pustules. These spots weep
and form yellow crusts. The infection can spread to other parts of
the body if the child scratches the spots, and it can also be passed
on to other children very easily. Treatment includes dabbing the
crusts with an antiseptic solution three or four times a day.
Influenza
It is a viral illness characterized by fever, headache, body ache,
cold, loss of appetite and vomiting. Influenza may take about 10
days to clear off. Helpful measures include vitamin C supplementation for speedy recovery and paracetamol for temperature
and aches. Antibiotics are of no help. Contact a doctor if your child
becomes very unwell or if she has very cold hands and feet, feels
sick or unusually thirsty or has a rash. This is because very
occasionally these are early signs of septicaemia (blood poisoning)
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from unrecognized bacterial meningitis. Another reason is that if

the child already has long-term heart, lung or kidney disease,
diabetes or poor immunity, she has a higher than average risk of
complications. Preventive measures include a single shot of
influenza vaccine every year. Risk of complications can be reduced
by the use of a drug called Zanamivir.
Jaundice
Yellow discoloration of the skin and the eyes is called jaundice.
Presence of excess of bilirubin, a yellow blood pigment produces
this condition. Normal harmless jaundice usually develops on the
second or third day of life and disappears without treatment after
about a week. Consult your doctor if your babys jaundice persists,
as untreated neonatal jaundice may lead to damage to the brain.
The treatment involves phototherapy or in severe cases exchange
transfusion. In contrast to newborn babies jaundice in older children
is never normal and usually indicates towards a serious underlying
problem and warrants urgent medical advice.
Knock Knees
Inability to bring the ankles together when the knees are together
is known as knock as knee. Mild knock knees improve on their
own by the age of 7-8 years. Medical advice is required if the
condition doesnt get better with age or is getting worse or if the
condition is severe.
Laryngitis
Inflammation of the voice box is known as laryngitis. Symptoms
include an attack of persistent cough in young children and
hoarseness or loss of voice in older children and adults.
Measles
Measles is a serious viral disease. Its usual time of occurrence is
2nd year of life, though it can occur at any age. Symptoms include
fever, runny nose, conjunctivitis and cough followed by rashes
which begins on the face and then spreads to the body and the
limbs. The fever subsides after the rash appears on the legs. After
this the rash also begins to fade. During illness the appetite goes
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down but the child should be made to drink plenty of water. There
is no specific treatment but paracetamol can be used to bring down
the temperature. Secondary infections require antibiotics. However,
the most effective measure against measles is vaccination at the
age of 9 months.
Meningitis
Inflammation of the covering of the brain and spinal cord due to
vial or bacterial infection is known as meningitis. Symptoms include
fever, headache, vomiting, aversion from light, drowsiness, painful
neck stiffness, excessive thirst, rash, cold hand and feet, convulsions,
irritability and lack of interest in the surroundings. The soft spot
(fontanelle) on his head may be fuller than usual, and he may have
a convulsion. One characteristic of bacterial meningitis is that its
rash does not fade on applying pressure. A child with these
symptoms should see a doctor urgently. If there is any suspicion of
meningitis, admit the child to hospital for examination of CSF (brain
fluid) and administration of antibiotics if the cause is bacterial.
Sometimes severe spread of bacteria and its toxin (septicaemia)
occurs before producing symptoms of meningitis. Its treatment is
on the same line as for meningitis.
Mouth Infections
Not infrequently, yeast infection produces white patches on the
tongue and the inside of the cheeks in babies, better known as oral
thrush. It can also occur on the babys bottom and cause nappy
rash. Thrush is not serious but it can cause discomfort when sucking
or feeding. The infection may have been passed on by the mother
at the time of birth, or have come from thrush on her nipples if she
is breastfeeding, or can develop after taking a course of antibiotics.
It can also arise if bottles have not been sterilized properly.
Antifungal drops can clear the mouth infection. Children
occasionally develop mouth ulcers, which usually appear on the
gums or the insides of the cheeks. They are caused by a viral
infection and should disappear within a few days. Less commonly,
herpes simplex viruses, which also cause cold sores, may be
responsible for a severe mouth ulcer. The child becomes unwell
and feverish, with small blisters on the tongue, gums, palate and
insides of the cheeks, which burst to leave painful ulcers. Eating is
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painful but soothing creams can be helpful. The child should be

made to drink plenty of water to avoid dehydration.
Mumps
Mumps is a viral infection that presents with painful swelling on
either side of the face in front and below the ears. The reason is
unilateral or bilateral involvement of the parotid glands. The
swelling usually reaches its peak two or three days later and
subsides over the next few days. Swelling of one gland may precede
that of the other by one or two days. The child may be feverish and
feel lethargic. There is no specific treatment, but the child should
be kept as comfortable as possible and can be given paracetamol
elixir if he has fever or the swelling is painful. He will be infectious
for about two weeks after the onset of the swelling. Rare
complications include mild meningitis and inflammation of the
testes (orchitis). Orchitis may occur in boys about eight days after
the parotid swelling. The testes become swollen and sore for about
four days, but the inflammation settles down without treatment.
Mumps induced orchitis in adults may result in permanent
testicular damage but in children no damage occurs.
Nappy Rash
Fungal infection or prolonged contact with wet and soiled nappies
may result in nappy rash. It can be caused by a fungal infection.
Such as thrush, or by a reaction of the skin to wet and soiled nappies.
To prevent or clear the rash, keep the babys bottom as clean and
dry as possible. This is best done by changing the nappy frequently
and leaving it off whenever possible to expose the skin to the air.
At each nappy change clean the babys bottom and apply a barrier
cream such as zinc and castor oil ointment. Avoid waterproof pants
as they keep the skin moist which exacerbates the problem. If you
use terry-towelling nappies, avoid washing them with biological
soap powder or strong detergent and rinse them thoroughly. Anti
fungal creams are effective in clearing rashes due to fungal infection.
Nosebleeds
Nosebleeds are usually caused due to regular nose picking or due
to infection of the nasal lining. Bleeding is best controlled by
pinching the soft part of the nose to close the nostrils. Apply
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pressure for at least five minutes to allow a clot to form. The child
should sit up and lean forwards so that no blood drips down the
throat. Try to stop the child touching or blowing her nose as this
can lead to more bleeding. Frequent nosebleeds require doctors
advice.
Obesity
Weight put on during early months of life is normal since, it is lost
during activity filled later years. Remember also that most toddlers
have little pot belies and this does not mean that they are
overweight. However, fat or obese children are more likely than
those who are average weight to become fat adults-a condition,
which increases the risks of heart disease, high blood pressure and
diabetes. You should avoid giving children too many stodgy, highcalorie foods such as ice cream, sweets, cakes, crisps and fizzy
drinks. Medical advice should be taken if obesity assumes
problematic proportion.
Phobias
Fear without a rational basis is known as phobia. The fear may be
intense and could be for anything, e.g. fear of ghost or animals in
the room. Phobias may represent hidden anxiety of a child
concerned about family or other problems. But, usually children
grow out of it with age. Usually sympathy and reassurance is all
that is required but persistent cases may require specialists advice.
Pica
Habit of eating inedible things is known as pica, and requires
doctors opinion. But, this should not be confused with the normal
act or normal infants and toddlers putting all kind of things into
their mouth out of natural inquisitiveness.
Pigeon Toes
Many children have their feet positioned in such a way that they
are turned inwards, which may force the child to trip over their
feet during running. No treatment is required as most cases get
corrected spontaneously by the age of seven years. However,
refractory cases may require orthopedicians advice.
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Prickly Heat
In hot and humid conditions, blockage of the sweat glands in the
skin may result in an itchy rash or very small blisters of sweat. This
condition is known as prickly heat. It can be prevented by using
cotton cloths and keeping the child cool. Since, the condition
improves on its own in a few days, so most cases dont require
may treatment.
Pyloric Stenosis
Repeated vomiting with each attempt of feeding along with a state
of constipation represents a condition known as pyloric stenosis.
The condition may occur any time between birth to upto 4 months
and results due to narrowing of the outlet of the stomach. The exact
reason behind the narrowing is not known but this outlet
obstruction prevents milk and food leaving the stomach normally.
As the quantity of milk filling the stomach increases, the baby
automatically vomits, which may be projectile. The result of
repeated vomiting is that the baby receives insufficient nourishment
from her food and loses weight. Despite this, she usually feeds well.
Treatment is either surgical or non-surgical with atropine sulphate.
Both options are very effective.
Rickets
Deficiency of vitamin D produces rickets. Most common cause of
rickets is the lack of exposure to sunlight. Sunlight enables the skin
to make vitamin D, which is also obtained from fatty foods such as
milk, fish, liver and cod liver oil, and what helps to control the
amount of calcium in the body. Calcium helps build strong bones
and teeth and, as a result of calcium deficiency, children with rickets
have soft bones which may become deformed, there may be some
swelling at the wrists and ankles. Prevention requires exposure to
sunlight and treatment requires vitamin D supplementation.
Ringworm
Fungal infection of the skin result in very itchy red scaly circles
known as ringworm. The scalp, body, groin, nails and feet may all
be affected. When it affects the feet it is known as athletes foot.
Ringworm on the body is sometimes contracted from an infected
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pet. Treatment requires antifungal ointments or tablets. Prevention

requires maintenance of hygiene and avoiding sharing of towels
and flannels.
Rubella
Infection with rubella virus results in rubella characterized by fever,
rash and enlargement of the lymph nodes (glands) at the back of
the neck. It is not a serious disease when it is caught by children
and generally lasts for only a few days. However, if the disease is
contracted during pregnancy (particularly in the first three months),
it can damage the baby in the womb. Because of this very serious
complication it is now recommended that all children should be
immunized against rubella in their second year. Rubella
immunization is usually combined with measles and mumps in
the one shot MMR vaccine (measles, mumps and rubella).
Infectivity of rubella extends a few days before the appearance of
rash to one day after the disappearance of symptoms. Exposure of
a pregnant woman to an infective child warrants immediate
medical advice.
Scoliosis
Abnormality of the bones, nerves or muscles of the back may result
in abnormal curvature of the spine known as scoliosis. The
condition should be managed by an orthopedician.
Sickle Cell Disease
Around the world people of African, Indian and Mediterranean
origin may suffer from an inherited disease of blood known as sickle
cell disease. It is characterize by anaemia and episodes of pain in
various parts of the body due to blockages of the blood vessels.
These episodes of pain are known as sickle cell crises, and are often
provoked by infections. A child with sickle cell disease has two
abnormal sickle cell genes in each body cell. If a child has a single
abnormal sickle cell gene in each cell (sickle cell trait) he will only
suffer from mild anaemia and is unlikely to have problems. There
is no cure for sickle cell disease, but blood transfusions can correct
anaemia and prompt medical treatment helps to relieve the painful
crises. A child with sickle cell disease has inherited an abnormal
gene from each of his parents and the parents have a one-in-four
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chance of having a similarly affected child in each subsequent

pregnancy. The miserly of the disease can be reduced to an extent
by giving folic acid supplementation and penicillin daily to
newborns identified by screening tests.
Sleep Walking
The cause of walking during sleep is unknown but it is supposed
to be associated with stress and as such is seen more often in school
going children rather than younger ones. A child found sleepwalking should be gently directed back to bed. Children who walk
in their sleep rarely harm themselves, but it is prudent to make
sure that the required safety measures have been confirmed against
all anticipated dangers to be faced during sleep walking.
Sore Throat
Inflammation of the throat and its contents due to viral or bacterial
infection is known as sore throat. A sore throat can occur by itself
or with a cold or infection of the ears (otitis media) or sinuses. Apart
from soreness of the throat, there may be tummy ache and earache,
a fever, irritability, loss of appetite, a cough, a runny nose and
swollen lymph nodes (glands) in the neck. Milk sore throats usually
last for only a few days and need no treatment. Keep your child at
home while he feels ill, cool him down if he has a fever, and let him
eat and drink, as he wants. A helpful home remedy is offering a
twice daily glass of hot lemon and honey, made by pouring 600 ml
of very hot water over the juice and rind of two lemons and adding
honey to taste. You may help your child feel better and speed
recovery by giving foods rich in vitamin C and flavonoids, or a
supplement of these nutrients. Steam inhalation is very helpful in
not only soothing the throat but also in clearing the virus. Antibiotics
may be required if the cause is bacterial, not only to control the
infection but also to prevent complications like rheumatic fever,
nephritis, otitis media, sinusitis and laryngitis.
Squint
Imbalance in the control of eye movements or short sightedness
may produce a condition were both eyes dont look in the same
direction. This is known as squint. Newborn babies sometimes have
a temporary squint which they quickly lose as control of the eyes
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develops. However, a persistent squint may prevent proper

development of vision, so any child or baby who appears to have
one should be seen by an ophthalmologist. The treatment may
include patching the good eye or surgery but it usually depends
on the underlying cause.
Stuttering
During normal phase of language development, children around
3-4 years often stumble and stutter during excitement. However,
children often grow out of it on their own, by the age of school
going. Faltering speech is not helped by an authoritarian attitude,
so it is better not to tell the child to slow down and repeat what he
is saying because this may frustrate and inhibit him. If he does
stutter, listen to him patiently and try not to draw attention to it.
Persistent problem may require speech therapy.
Styes
A boil at the base of an eyelash is known as stye. The doctor will
prescribe an antibiotic ointment. Cotton wool soaked in warm water
and applied to the stye may help to alleviate discomfort in the first
place but antibiotics may be required to control the infection.
Sunburn
Prolonged exposure to direct sunlight specially in babies and young
children may result in sunburn. Few hours after the exposure,
sunburn may become noticeable in the form of tender skin and
blisters. Treatment includes soothing by application of cold water,
calamine lotion or aloe Vera gel or calendula cream. Other helpful
measures include vitamin C and E supplementation. Severe cases
may require appropriate rehydration. Preventive measures include
protection from exposure to excess of direct sunlight and use of
sun hat and sun cream.
Glands
When ever infection occurs the lymph nodes in the near by area
becomes enlarged and is popularly known as glands. For example,
infection in the legs may produce enlargement of the groin glands,
infection of arms produce enlargement of the armpit glands,
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infection of the throat results in enlargement of the neck glands.

Glands return to their normal size as the infection subsides,
however, persistent enlargement of glands requires medical
opinion.
Testes
In the womb the testes starts as an abdominal organ and gradually
moves down with the growth of the foetus to ultimately lodge itself
into the scrotum. Occasionally this descent is incomplete at the time
of birth so that one or both of the testes are undescended and cannot
be felt in the scrotum. Most undescended testes come down into
the scrotum during the first year, but when this does not happen,
operative fixation of the testes into the scrotum is done to allow its
normal development. A retractile testis is one that intermittently
escapes from the scrotum into the groin. It differs from an
undescended testis in that it can be coaxed down into the scrotum
and requires no treatment, as it will remain permanently in place
in time. Torsion of a testis occurs when it twists on its stalk. This
causes sudden pain in the testis, the child may feel sick and vomit
and the testis may be swollen and tender. This is a medical
emergency and requires urgent treatment, which may be surgical.
Tetanus
Infection with a bacteria called clostridium tetni results in a lifethreatening illness known as tetanus. The bacteria lives in soil and
gains access into the body through wounds contaminated with
soiled objects. In the body the bacteria produces a toxic substance,
which puts the muscles of the body into spasm. The condition can
be prevented by a tetanus immunization, which all children should
have during the first year of life. A tetanus booster is given at the
age of five, or to any child who sustains a dirty injury and has not
had a booster for the past five years. Treatment requires
hospitalization and administration of tetanus immunoglobulin,
muscle relaxants, sedatives and antibiotics.
Thalassemia
People of Mediterranean, African or Asian origin may suffer from
a hereditary abnormality of hemoglobin production resulting in
anaemia. This condition is known as thalassemia. A single abnormal
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thalassemia gene in each body cell does not cause significant

anaemia, but if a child has two abnormal genes in each cell she will
develop anaemia and require regular blood transfusions. A child
with thalassemia major has inherited one abnormal gene from each
parent and the parents will have a one in four chance of producing
another affected child in each subsequent pregnancy. Although,
not much treatment options are available currently, gene therapy
is being looked with great hope.
Threadworms
Threadworm, the most common of the bowel parasites, live in the
lower bowel and lay their eggs around the anus. These tiny worms
do not usually cause any symptoms, but they may make the childs
bottom itchy. The eggs are too small to be seen with the naked eye,
but occasionally worms may be seen around the anus or on the
bedding; they are about 1 cm long and look like slender white
thread. The infection is passed on by scratching the bottom, getting
the eggs onto hands and then putting the fingers into the mouth.
Routine examination of the stool can identify the condition.
Treatment is with drugs like albendazole.
Tongue Tie
Tongue tie is a condition in which normal protrusion of tongue is
prevented due to extension of the tissue joining the tongue with
the floor of the mouth to the tip of the tongue. In the vast majority
of cases this presents no problem to the child and improves as she
gets older, but very rarely a tongue tie may be tight enough to
prevent a child from making certain sounds properly. Treatment
is surgical excision of the abnormal tissue strip.
Tonsillitis
The tonsils are patches of lymph tissue on either side of the back of
the throat. Tonsillitis occurs when the tonsils become inflamed due
to a bacterial or viral infection. The child with tonsillitis has a sore
throat and fever, and may feel generally unwell and be off her food.
The lymph nodes under the chin and neck, which drain the tonsils,
also become enlarged. If bacterial tonsillitis is suspected antibiotics
will be required; otherwise treatment includes paracetamol elixir
and plenty to drink. You can also use the home remedies suggested
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for a sore throat. Tonsillitis usually gets better after three to four
days.
Toothache
Toothache can be caused by decay of a tooth (caries), inflammation
of the root of a tooth (a tooth abscess) or a gum infection. Sometimes
pain caused by inflammation of the ear or jaw bone can feel like
toothache. A child with toothache should be seen by a dentist first,
but if the dentist can find nothing wrong with the childs teeth,
consult your doctor.
Travel Sickness
The tendency to feel ill or vomiting during traveling is known as
travel sickness. It is the movement, which causes the sickness, so it
can occur in a plane, boat, car or even on a merry-go-round. If your
child readily vomits in such situations, encourage her to sit still
during journeys, preferably by an open window and looking in
the direction in which she is traveling. Antihistamines may be
helpful in preventing travel sickness, but they should be taken at
least half an hour before the start of the journey. One useful tip for
preventing travel sickness is to give your child ginger tea made by
boiling 50 gm of freshly cut ginger in 600 ml of water for 10 minutes
and sweetening it as per taste.
Tuberculosis
Infection with bacteria called mycobacterium tuberculosis results
in this disease. It can affect other parts of the body, such as the
lungs, brain, neck lymph nodes (glands), bones and kidneys.
Treatment for the disease is with antituberculosis drugs continued
for some months. It is acquired either through close contact with
some one who has TB of the lung or by drinking milk from infected
cattle. Immunization with BCG vaccine can be used to protect from
this disease.
Tummyache
There are many reasons for tummyache. Children can have
tummyache with something as simple as a sore throat or cold. This
is because the lymph nodes (gland) in the abdomen become
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enlarged as part of the bodys reaction to the infection, causing

irritation to the bowel and thus pain. This type of pain settles
without treatment, but make sure your child takes plenty of fluids.
Sometimes children, complain of tummy aches when they are
anxious. These pains are similar to the tension headaches, which
some adults develop when stressed. In between the bouts of pain
the child is well and no treatment is required, but it may be helpful
to find out what is upsetting them. This occurs more frequently in
school children than toddlers. Tummy ache may also occur with
other symptoms. When accompanied by frequent vomiting or a
change in the bowel motions (diarrhoea or constipation) it could
be caused by an infection of the bowel. Such as gastroenteritis, by
appendicitis or by an obstruction in the bowel. A tummy ache
combined with blood in the bowel motions may be caused by a
bowel infection or obstruction. If the child is urinating very
frequently, the pain may be due to a urinary infection. A child who
has any one of these complaints appears unwell, loses her appetite
and energy and may be feverish. The pain probably comes and
goes, but even when it is not acute the child is not her usual self.
Other causes of tummy ache include food sensitivity, asthma, sickle
cell anaemia, cystic fibrosis, diabetes, lead poisoning and
indigestion. Medical advice should be seeked if tummyache is
persistent or associated with symptoms above mentioned.
Urinary Tract Infections
Bacterial infection in any part of the urinary tract that includes
urethra, bladder, ureters and the kidneys can result in fever, pain
on passing urine, needing to pass urine more frequently than usual,
passing blood in the urine, abdominal pain, vomiting, irritability,
unwillingness to geed and loose motions. A urine sample can be
tested to discover what sort of infection (if any) is present. If urine
infection is confirmed, the child should be given plenty of fluid
and appropriate antibiotics. Symptoms can be eased with homemade lemon barley water, made by boiling barley in water for fortyfive minutes, straining and flavoring with lemon juice and honey.
Alternatively, make the urine less acid by adding half a level
teaspoon of sodium bicarbonate to every third glass of fluid the
child drinks. After completion of the antibiotic course, urine sample
should be rechecked to confirm elimination of the infection.
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Urticaria
Sometimes itchy wheals and blotches on the skin can be produced
by an allergic condition known as urticaria or hives. The allergic
factor can be any thing like drugs, pollens, certain foods, infection
and even cold whether and water. The rash usually clears up after
a few days, but calamine lotion may be soothing and antihistamines
can reduce itchiness.
Vaginal Infection
Due to the effect of the mothers hormones, thick white or blood
stained vaginal discharge may occur in newborn girls. This is
normal and usually disappears in first few weeks. In young girls
the skin of the vulva and vagina is very delicate so that irritation or
infection can easily cause inflammation and discharge. Tight
trousers and rough textured tights should be avoided as they rub
against the skin. Some types of bubble bath also cause irritation,
occasionally the bottom scratching associated with threadworms
can damage the vulval skin and cause a slight infection. If a child
has a sore vulva, with or without a discharge, it may be helpful to
use milk soap for washing, avoid bubble bath and see that she wears
cotton pants. Hormone cream may be used to increase skins
resistance to irritation. Discharge due to bacterial infection requires
antibiotics.
Vomiting
Expulsion of stomach contents is known as vomiting, however, it
should not be confused with regurgitation of small amount of milk
after feeds in babies, which is normal. Vomiting can result from
any reason like bowel obstruction or infection. Medical advice is
warranted if vomiting is persistent or associated with features of
serious illness like diarrhoea or feeling difficulties, headache, and
pain abdomen. Treatment is that of the under lying cause.
Warts
Warts are bad looking small growths on skin, which may be
uncomfortable but are usually not serious. They are caused by virus
and their usual site of occurrence include fingers, hands, elbows
and face. They usually disappear spontaneously but helpful
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measure includes application of carbon dioxide snow, chemical

paints or liquid nitrogen. A verruca is a wart on the sole of the foot.
Because of its position in the thick skin under the foot it produces a
small hard lump. A verruca is painless, except when a child is
standing or walking, when it presses into the foot and may feel like
a pebble in the shoe. Treatment of verruca is similar to that of warts.
Wax in Ears
Protection of the lining of the ear and clearance of the dust particles
is dependent upon wax produced normally by the ears. When
cleaning your childs ears it is only necessary to wipe wax from
outside. Poking deep into the ear should be avoided as the eardrum
might get damaged.
Whooping Cough
Infection with bacteria called bordetella pertussis results in
whooping cough. It is characterized by cold followed by cough
with a characteristic whoop. The cough comes in spasms and
usually makes the child red in the face. He may also vomit after an
episode of coughing. The number of coughing bouts per day varies
and the condition may continue for several weeks, with the child
remaining infectious for up to three weeks after the cough begins.
Whooping cough is most dangerous in small babies because the
coughing spasms interfere with normal breathing and feeding.
Whooping cough can be prevented by immunization. Whooping
cough immunization is usually administered with diphtheria and
tetanus vaccine, but it may not be recommended if your baby suffers
from fits or has brain damage, or if a close relative of the child
(parents, brothers or sisters) has a history of fits or epilepsy.
Treatment includes administration of antibiotics like erythromycin,
but it only helps in making the child less infectious, and has no
bearing on the course of the disease.
Excessive Crying
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Since, crying is the only means of communication, the baby uses it

quite liberally to meet his needs. However, by the time the child
becomes three to four months old, the crying spells lessen, partly
because the parents begin to understand the needs of their babies
better and partly also because the child has diversions like
exploration of the world around him. Still the parents are always
in need of ways to soothe their babies.
Ways to Handle Crying in Newborns
Since, hunger is the most likely reason for crying in the first month,
offering feeds is the best way to cope with the problem. Bottle feed
babies have extra demand for water so they may also cry due to
thirst as indicated by hungry sucking with short gaps between the
feed. Offering boiled and cooled water should calm the baby.
Sometimes wind makes the baby cry, which can be helped by
holding the baby upright against the shoulder or in a face down
position in the arms.
Being in the lap of unfamiliar face for long periods can also
make the baby cry and this requires loving cuddle by a familiar
parent to quieting the baby.
A fractious baby can be comforted and made to sleep by putting
her into rhythmic movements like jigging up and down or rocking
to and fro in the arms or carry cot or rocking chair.
It may be comforting for the baby to feel secure and safe if she
is wrapped up firmly but gently in a big enough piece of soft cloth
with ends tucked under her to make a good bundle. Carrying the
baby in this bundled up position may quiten the baby or put her to
sleep. Swaddling is also very effective in quitening a baby crying
due to particular acts like washing or dressing.
148
The feel of a familiar hand is often very comforting, so patting

or rubbing rhythmically on the back or tummy is usually effective
in calming down a crying baby.
Sucking calms most of the babies. Parents can use their clean
little finger to pacify the baby or put her to sleep. Provided sterilized
before every use, dummy teats with a natural contour can also be
tried.
Distracting the baby by making her look at bright colorful things
can sometimes make the baby forget the reason of her crying.
Making the baby see photographs or her own reflection in a mirror
has been found to be very effective.
Causes of Crying in Younger Babies
Most of the times the parents do not really know the exact cause of
crying. If all the above mentioned simple measures of quitening
the baby has failed then following reasons should be cross checked.
Illness as indicated by unusual symptoms or unusual sound of
cry or even minor problems like blocked nose may make the baby
irritable. Consult a doctor for appropriate treatment of the baby.
Crying due to nappy rash can be helped by taking of the nappy
and cleaning the baby thoroughly and then the baby should be left
bare and dry for the rest of the day. Appropriate steps should be
taken to control the rash.
Between the age of 2 to 3 weeks to 2 to 4 months, the baby may
cry intensely for hours every day, usually in the evening. This is
known as evening colic. Colic is neither harmful nor much can be
done to help the baby. The earlier the parents learn to live with the
fact that, it is not a harmful condition and will go away on its own
by the age of 3 to 4 months, the better it is for both parents and the
baby. During an attack of colic every simple measures (already
described) should be tried out to provide at least temporary relief.
Since, colic cannot be cured so medicines should be avoided as far
as possible. However, gripe water is harmless and can be tried.
Uncomfortable surrounding like bright light shining in the eyes
or very cold or very hot temperature around can make the baby
cry. Care should be taken to avoid bright light falling directly into
the babys eyes. The baby should not be over dressed or under
dressed. The living room of the baby should be maintained at a
thermoneutral temperature.
Excessive Crying
149
Crying due to disliked but necessary acts like bathing, dressing

and undressing and medicine application can be tackled by
completing the act as quickly as possible followed by loving cuddle.
Sometimes the babies cry in reaction to the bad mood of their
parents. Just realizing this fact can bring the necessary mood
changes.
Over reacting to babies cry without any obvious reason can
sometimes make the baby cry even louder. So, the care should be
taken to avoid unnecessary acts like repetitive feeding and
undressing and dressing without a requirement. Discussion in loud
voice over any problem like the babies cry should be avoided. More
often than not, simple cuddling or rocking or patting does the trick.
Crying in Older Babies
Around the age of about three months, crying lessens, partly
because the baby becomes more responsive to the surrounding and
partly also because the parents begin to understand their babies
better.
Causes of Crying in Older Babies
Even in older babies, hunger is the prime reason for crying. Since,
older babies are more mobile so their energy consumption is greater
and as such may require additional doses of food or drink to remain
cheerful.
Around the age of 7 months, the baby discovers her attachment
with her parents and as such does not want to loose sight of the
parents even while playing. Loosing sight of her parents can make
the baby cry. Parents should exercise patience and encourage the
baby to get used to new situations and people.
As the baby gets more mobile she becomes more prone to
injuries. Often injuries or even the shock of injury can make the
baby cry. Distracting or cuddling the baby is usually enough to
quiten.
From around the age of 2 years, the baby may become irritable
and frustrated if not allowed to do things her own way. This could
be due to age related inability or parental assertion of will over the
baby. If the baby becomes angry and starts throwing tantrums, she
should be dealt with patiently. The tantrums should be avoided
completely and efforts should be made to reason out the child ones
150
the tantrums have passed. Age related in ability can make the baby
cry because she can do things she wants too. The parents can help
the baby by distracting or by providing a helping hand without
taking over the babys job.
Around the age of one year the child remains so very much
excited with new experiences that he hardly relaxes inspite of being
totally exhausted. This may lead to tiredness and crying. The child
can be helped by making him relax and sleep by providing calm,
quite and soothing surrounding at the bed time.
Teething can also result in crying and irritability. The baby can
be helped by rubbing the gums with the little finger or by giving
the child something to chew like carrot specially if it has been
chilled. Giving teething medicines should be avoided.
First AID
C
H
A
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T
E
R
29
Often first aid is the most important treatment that one can provide
in case of an eventuality. Every home should have a first aid box
kept unlocked and at a place inaccessible to children and easily
accessible to adults.
Contents of a First AID Box
Box of assorted sticking plasters

Packet of absorbent cotton wool
Box of sterile gauze dressings
Roll of 5 cm (2 in) gauze bandage
Nonadhesive sterile dressings (for burns and blisters)
2 or 3 crepe bandages for sprains
Sterilized eye pad with bandages
Large triangular bandage, or a piece of clean white linen, to use
as a sling or dressing for burns.
Safety pins and surgical tape for securing bandages
Scissors
Blunt-ended tweezers
Paracetamol elixir
Calamine lotion for soothing sunburn and stings
Thermometer or fever strip
Tube of eye ointment
Antiseptic wipes for cleaning around a wound.
Animal Bites
Serious bites warrant medical advice, however, superficial bites
may need only wound cleaning and sterile dressing application.
But, tetanus booster is a must irrespective of the seriousness of the
wound.
152
Blisters
Burn or friction are the usual cause of blisters. Never prick a blister
as it forms a protective layer between the skin and damaged area,
which protects against infection. Cover the blister with a nonadherent dressing kept in place with sticking plaster. Burst blisters
should be kept clean and dry to prevent infection.
Convulsions
A convulsing child should never be left alone. In case he vomits
and chokes, put him in the recovery position and loosen his clothing.
Dont try to restrain him. Arrange to have medical advice as soon
as possible.
Crushed Fingers
Put the hand under cold water or apply cold compresses to reduce
swelling and pain. After the child has been comforted to an extent,
cover his hand loosely with a piece of clean cloth to avoid further
knocks. Doctors advice may be taken if the condition remains
painful for prolonged period.
Cuts and Grazes
First aid of miner cuts and grazes warrants cleaning the wound
with warm water and wiping from the middle outwards. Use each
swab once only to help prevent cross infection. Pat the skin round
the cut or graze, dry and cover with a dressing or sticking plaster.
For heavy bleeding following steps should be taken:
Keep the child still and firmly press the would with clean hand
or a piece of clean cloth and at the same time raise the injured
area till bleeding stops.
If there is a bone protruding, or a piece of glass or sharp object
in the wound, press around the edges of the wound, not directly
on to it. Dont remove anything from a wound as it may be
acting as a plug to stop the bleeding.
Cover the wound with a bandage to prevent infection.
Consult a doctor as soon as possible as the wound may need
stitches or the child might be going into shock.
First AID
153
Eye Injuries
Do not allow your child to rub the eye. Washing the eye with clean
water can remove small objects such as grit or dirt. Foreign body
in the eye should be removed gently with the tip of a clean cloth. If
the injury has been caused by a chemical, put the childs head on
one side and flush the eye with cold water. Be sure to wash from
the inside corner of the eye outwards. This ensures that chemicals
are not washed across the face and possibly into the other eye.
Apply an eye pad and seek eye specialists advice as soon as
possible.
Foreign Body in the Ear
If an insect has gone into the ear, lie the child on his side and gently
pour warm water into it so that the insect floats to the surface. If
this doesnt work, get medical help. Dont pour water into the ear
if the child has grommets fitted or if there is a foreign body other
than an insect, as it could cause the object to swell. Dont try to
remove the object yourself as you may wedge it in more firmly.
Take the child to an ENT specialist as soon as possible.
Foreign Body in the Nose
Make the child blow through the affected nostril while other one is
covered. If this fails in dislodging the object, consult an ENT
specialist.
Heatstroke
Watch for signs of overheating like raise temperature, restlessness,
flushing and ill looks. Remove the clothes of the child and keep
him cool and still and make him drink plenty of water. Consult a
doctor as soon as possible.
Insect Bites and Stings
Cover the bites to prevent your child scratching, as this only makes
the irritation worse. Calamine lotion is very soothing for insect bites.
A bee or wasp sting can be very painful and alarming. If you can
see the sting, pull it out with a pair of tweezers, but if you cant or
its too deep-dont try to squeeze it out or youll cause more pain
and inflammation. A piece of cotton wool soaked in a solution of
154
bicarbonate of soda (diluted vinegar for a wasp sting) and held

over the sting is a good household remedy. A cold compress helps
reduce pain and swelling. If the child has been stung in the mouth
there may be a lot of swelling. Make the child to rinse his mouth
out with a solution of bicarbonate of soda and give him a lump of
ice to suck and arrange for urgent medical advice.
Snakebite
Make the child lie down and keep him as still as possible. Dont
raise the affected limb. Wash the wound thoroughly with soap and
water. Send for medical help, and reassure your child. For the
administration of the correct anti-venom, it is very important that
the look of the snake is correctly described to the doctor.
Splinters
Dont try to pull out a splinter of glass or metal yourself but leave
this to the doctor. Small splinters sticking out from the skin can be
pulled out with a pair of tweezers. A splinter under the skin can be
squeezed and taken out with a sterilized needle that has been passed
through a flame and cooled. Calm and reassure your child as you
remove the splinter, as it is likely to be painful. Doctors advice
should be seeked if the skin becomes infected.
Sprains
Put the child in such a position that the affected limb rests in a
comfortable raised position without bearing any weight. Swelling
if any can be helped by cold compresses.
Emergencies
C
H
A
P
T
E
R
30
It is always prudent to have some knowledge of some of the life

saving techniques.
Mouth-to-Mouth Ventilation
If a child has stopped breathing, immediate mouth-to-mouth
ventilation can be life saving even if it is thought to be too late. The
air breathe into childs lungs contains enough oxygen to save the
life of the child. Till specialize medical help reaches, following steps
should be taken:
1. Lie the child on his back. Clear his mouth of any foreign bodies,
blood or vomit.
2. Tilt the head back slightly with one hand and lift the chin up
and forward with the other so that his tongue is not blocking
his throat.
3. Pinch the childs nostrils to close off the nasal airway and seal
your mouth over his open mouth (for small children and babies,
cover their mouth and nose). Blow into the childs mouth and
check that the chest rises.
4. Remove your lips and allow the chest to fall.
5. Give one breath about every three seconds and keep on with
this until the child starts to breathe, or professional help arrives.
6. When the child is breathing again, gently turn him over and
place him in the recovery position.
Heart Massage (Chest Compressions)
If the heart has stopped, the child will not breath after the initial
attempts of mouth-to-mouth ventilation and instead may turn blue
or pale. Pulse of the child should be checked and if found absent,
both heart massage and mouth-to-mouth ventilation should be
156
given simultaneously. The helping man should kneel beside the

child lying in prone position.
Steps
For Child of One Year or More
The lower part of the breast bone of the child should be pressed
firmly but gently with the pad of the hand. Press down to a depth
of 3 cm (at a rate of about 100 compressions per minute thats
faster than one a second)
For a Baby Less than One Year
1. Instead of pad of the hand, two fingers should be used. Depth
of compression should be 2 cm. Rate of compression should be
about 100 compressions per minute.
2. Mouth-to-mouth ventilation should be given after every five
compressions. If there is some one with you, one of you can do
heart massage, stopping after five compressions for the other
to breathe into the childs lungs. Every three minutes the pulse
should be checked.
3. Heart massage should be stopped after the pulse becomes
palpable. Mouth-to-mouth ventilation should be continued until
breathing starts, or medical help arrives.
The Recovery Position
A breathing but drowsy or unconscious child should be placed in
a recovery position since in other positions; the throat may get
blocked by the tongue or vomitus.
1. Kneel beside the child, tilt his head back and lift his chin up,
then straighten his legs. Put the nearest arm at right angles to
the body, elbow bent and palm uppermost. Bring the furthest
arm across the chest, holding the hand, palm outwards, against
the childs cheek nearest you.
2. Using your other hand, pull the knee furthest from you up, with
the foot flat on the ground. Pull that legs thigh towards you to
roll the child on to his side. The hip and knee of this upper leg
should now be bent at right angles. The air way should be kept
open by tilting the head back.
Emergencies
157
Scalds and Burns

Contact with hot liquid or steam produces scalds, where as contact
with fire, chemicals, electricity can result in burns.
A scald or burn can be serious if face or other sensitive part of
the body is involved or very large area is affected or the wound is
very deep. The danger with serious burns or scalds is that fluid
(Plasma) can be lost from the skin. This is particularly serious in
young children, when it can rapidly lead to shock.
1. To take the heat out of the skin the affected area should be
immersed in cold water for at least 10 minutes.
2. As the skin can swell up, so the clothing should be taken off.
3. Serious burn requires specialize medical treatment whereas
minor injuries can be dealt by putting clean nonadhesive cloth
over the area to prevent infection.
Clothes on Fire
Clothings of the child should be doused in water if available or the
fire can be smothered by putting the child on the ground and
covering him with a heavy blanket. Synthetic fabrics should not be
used. As a last resort, use your own body to smother the flames.
However, make sure there is no gap between your bodies where
air might get through and fan the flames. When the flames are
smothered, immerse the burnt area in cold water. If clothes are
stuck to the skin, dont pull them off and dont burst any blisters.
The child should be made to drink as much of water as he can on
way to the hospital.
Choking
First look in mouth and remove any obvious object.
For a child over one year- lie him over your knee with his head
down. Give him five sharp slaps between his shoulder blades to
dislodge the object.
1. For a baby hold him face down over your arm (or pick him up
by his legs and hold him upside down) and give him five sharp
slaps between the shoulder blades.
2. Check mouth again for easily removed object. Dont remove
anything at the back of the throat as you may wedge it in further.
If this doesnt work, for a child, give five chest thrusts similar
to chest compressions but slower (about 20 per minute).
Follow with five further back slaps. If necessary, follow this
158
by lying the child face up and giving five short sharp thrusts
to the upper abdomen (between the navel and breastbone).
Repeat the sequence of back thrusts, chest thrusts, back slaps,
abdominal thrusts.
For a baby, follow the five back slaps with five chest thrusts
and repeat the sequence of back slaps with chest thrusts. Do
not do abdominal thrusts on a baby.
Give mouth-to-mouth ventilation if breathing stops.
Drowning
Get your child out of the water, if possible. If it is not, give
emergency first aid in the water.
1. Empty the childs mouth and, if breathing has stopped, give
mouth-to-mouth ventilation.
2. Send someone to call a doctor or ambulance and carry on with
mouth-to-mouth ventilation until help arrives. Be prepared to
start heart massage.
Electric Shock
Dont touch the child as the shock can be transmitted to you.
1. Switch off the source of electricity at the mains immediately or
pullout the plug. If this is not possible, break the electrical contact
with something which does not conduct electricity, such as a
wooden broom, and push your child away from the wire or
socket. If there is water around, do not stand in it as water
conducts electricity.
2. Check your childs breathing and, if he is breathing but
unconscious, place him in the recovery position your child may
need to be treated for burns or for shock so take him to the
nearest hospital.
Dislocations and Fractures
When a bone moves away from its position in a joint, it is called
dislocation. When a bone breaks partly or completely, it is known
as fractures, it may be difficult to distinguish between a fracture
and a dislocation, so follow the same emergency procedure for both.
Dont move the child unless you have to, especially if you think he
might have injured his back or neck. Make him comfortable and
get medical help. The affected limb should be immobilized before
moving the child.
Emergencies
159
Broken leg should be dealt by placing some padding between

the legs and tie the injured leg gently but firmly to the other leg
with bandages. Broken arm should be dealt by using a triangular
bandage to make a sling. Gently bend the injured arm across the
chest and slide one end of the bandage between the elbow and the
chest and over the shoulder. Bring the other end over the arm and
wrist, and tie the two ends at one shoulder.
Head Injuries
Although trivial head injuries are usually harmless but medical
advice should not be delayed if the child shows following symptoms
ear or nasal discharge, headache, vomiting, dizziness, drowsiness,
unconsciousness or seizures.
Shock
Shock is a serious condition characterized by rapid pulse, rapid
breathing, sweating, pallor, nausea, delirium, faintness and very
ill feeling. Make the child like down with his head turned to one
side. Loosen clothing and raise his legs. Keep him warm but not
too hot (for example, lightly cover him with a blanket but dont
give him a hot-water bottle). Arrange for urgent medical help if
the child becomes unconscious or is conscious but showing after
effects of the illness.
Poisoning
Urgent hospitalization should be arranged when ever poisoning is
suspected. Care should also be taken to carry the container of the
poison to provide correct knowledge about the type of poisoning
to help right kind of treatment.
If the child is vomiting, choking can be prevented by holding
the child with his body bent forward.
Give the child frequent sips of cold milk or water if he has burnt
his lips by swallowing corrosive poison, provided he is conscious.
Avoid giving sickening drinks like salt water specially if
corrosive poison has been swallowed.
Suffocation/Smothering
Remove the suffocating factor and give mouth-to-mouth ventilation
if breathing has stopped.
Index
A
Abdominal muscle 13
Abscess 111
Abuse
cocaine and pregnancy 24
during pregnancy and fetus 22
fetal impact of opiate 23
maternal impact of opiate 23
opiate and pregnancy 23
Acebutolol 44
Adenoids 111
Alcohol 8
Alcoholism and pregnancy 25
Allergic rhinitis 111
Allergy 112
Amphetamine 42
Anemia 112
Antenatal care 7, 20
Antianxiety 43
Anticonvulsant therapy 16
Antidepressants 43
Antipsychotic drugs 44
Appendicitis 113
Areas of concern in breastfeeding 35
Areas of work 58
Aspirin 44
Asthma 113
Atenolol 44
B
Baby in womb 2
Babys condition 63
Babys development in womb 2
Back 12
Bed wetting 114
Benefits of bilirubin 75
Blood in urine or bowel motions 115
Bow legs 115

Breastfeeding 35
advantages 36
best investment 51
contraindications 41
factors 62
good start 39
how to feed 39
midnight feeds 41
promotion network of India 57
questions and their answers 65-67
resource 52
Breath holding 116
Bromocriptine 44
Bronchiolitis 116
Bronchitis 117
Bruises 117
C
Caffeine and pregnancy 26
Caloric value 104-106
Carbamazepine 17
Carbohydrate 54
Care of body 12
Chickenpox 117
Choking 157
Cleft palate 118
Clemastine 44
Clinical manifestations of
fetal alcohol syndrome 25
neonatal 23
Clubfoot 118
Cocaine 42
Coeliac disease 118
Cold sore 119
Colic 119
Color blindness 120
162
Congenital dislocated hip 120

Conjunctivitis 120
Constipation 11
Consumer groups 60
Convulsions 121
Cost of bottle feeding 52
Cough 122
Cradle cap 122
Cramp 13
Croup 123
Crying excessive 147
Crying in
newborns 147
older babies 149
younger babies 148
Cyanosis 123
Cyclophosphamide 42
Cyclosporine 42
Cystic fibrosis 123
Cytotoxic drugs 42
Fat 54
Feeding schedule 40
Fetus 3
Fever 127
First AID
Dandruff 124
Dehydration fever 51
Dental decay 124
Detection of diabetes in pregnancy 19
Development
in mothers during pregnancy 4
physical and mental 92-95
Diabetes 125
Diabetes and pregnancy 19
effects on fetus and neonate 17
Diapering and diaper dermatitis 82
Diarrhea 125
Diet 10
Diphtheria 126
Discomfort 10
Dislocations and fractures 158
Doxorubicin 42
Drowning 158
Drugs of abuse 42
Dyslexia 126
Earache 126
Eczema 127
Eczema and allergic diseases 37
Electric shock 158
Embryo 3
Emergencies 155
Emollition 81
Emotional changes 14
Energy 54
Enough breast milk 62
Enzymes 55
Epilepsy and pregnancy 16
Ergotamine 44
Erythema infectiosum 128
Exercise 7
Exercises general 13
animal bites 151

blisters 152
convulsions 152
crushed fingers 152
cuts and grazes 152
eye injuries 153
foreign body
in the ear 153
in the nose 153
heatstroke 153
insect bites and stings 153
snakebite 154
splinters 154
Flat feet 128

Fluoride 55
Food sensitivity 128
Index
G
Gastroenteritis 129
Gestational diabetes 18
Glands 140
Glue ear 130
Goals 57
Grass-roots 59
Growing pains 130
Growth factors and hormones 54
Jaundice
breast milk 76
in newborn 75
management 77
pathological 76
physiological 76
prevention 78
Laryngitis 133
Leg cramps 11
Lithium 44
Hair and skin 9

Hare or cleft lip 130
Head
banging 131
injuries 159
lice 131
Headache 130
Heart
burn 11
massage 155
murmur 131
Heroin 42
Hiccups 51
HIV 27
breastfeeding transmission 28
infection in mother 29
prevention of perinatal 28
transmission from mother
to baby 27
Hygiene of care givers 79

Hyperactivity 132
Hypoxia 17
I
Immunization 90-91
Impetigo 132
Infant formula industry 59
Influenza 132
Intrapartum 16, 27
Iron 55
163
M
Marijuana 42
Maternal medication 45
Measles 133
Methotrexate 42
Mid night feeds 41
Minor problems 13
Morning sickness 11
Mothers psychological factors 63
Mothers physical condition 63
Mouth infections 134
Mouth-to-mouth ventilation 155
Mumps 135
N
Nappy rash 135
Neonatal skin care 79
NGO groups 60
Nosebleeds 135
Not enough milk 61
Numb fingers 14
Nutrition in pregnancy 107-110
Nutritional components
of breast milk 53
P
Pelvic floor muscles 13
Pelvic joints 12
164
Phencyclidine 42
Phenindione 44
Phenobarbital 45
Phimosis and circumcision 117
Phobias 136
Physical activity tips 97
Pica 136
Pigeon toes 136
Piles 11
Placental abruption 17
Poisoning 159
Policy and planning 59
Postnatal care 16, 21
Postpartum 27
Practical approach for health
professionals 62
Precautions 10
Pregnancy 2, 7
care 7
diabetic 20
drugs 31-34
Preparation of babys feed 68
Preparing the feed from powder 68
Preparing with ready-to-feed 68
Prevent child abuse and neglect 98
Prickly heat 137
Primidone 45
Production of breast milk 50
Professional bodies 59
Protection against infections 36
Protein and energy 56
Protein 53
Public health issues 30
Pyloric stenosis 137
postpartum exposure to HIV 29

risk for infection if exposed 29
viral load in mother 29
Regurgitation 51
Rest and sleep 8
Rib flare 14
Rickets 137
Ringworm 137
Rubella 138
S
Scalds and burns 157
Scoliosis 138
Sexual intercourse 8
Shock 159
Sickle cell disease 138
Slapped cheek disease 128
Sleep walking 139
Smoking and pregnancy 26
Sore throat 139
Spacing of pregnancy 38
Squint 139
Sterilizing the equipment 68
Storage of breast milk 50
Stuttering 140
Styes 140
Success of BPNI effort in India 59
Successful breastfeeding 40
Suffocation/smothering 159
Sulfasalazine 45
Sunburn 140
Swelling of ankles 11
Swollen ankles 14
Questions 70-74
Quickening 5
Quinine 31, 32
Target groups 58
Teeth 9
Tension and relaxation 14
Testes 141
Tetanus 141
Thalassemia 141
Threadworms 142
Tobacco 8
R
Radioactive compounds 42
Reduction of
exposure of fetus at delivery 29
Index
Tongue tie 142
Tonsillitis 142
Toothache 143
Travel sickness 143
Travel 9
Tuberculosis 143
Tummyache 143
U
Umbilical cord care 80
Underfeeding 51
Urinary tract infections 144
Urticaria 145
V
Vaginal infection 145
Vitamins 55, 99-103
D 55
K 55
Vomiting 51, 145
W
Warning signs for suicide 96
Warts 145
Wax in ears 146
Weaning
age of introduction 84
feeding practice 86
foods 86
hygiene and care 87
solid foods 88
tips 87
Weight control 10
Whooping cough 146
165
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Mother and Child Care

No book can be written without indebtedness to many people.

2. Pregnancy and Baby in Womb

3. Care During Pregnancy

4. Care of Body During Pregnancy

5. Epilepsy and Pregnancy

6. Diabetes Mellitus and Pregnancy

7. Substance Abuse During Pregnancy and Fetus

8. HIV/AIDS in Mother and Children

9. Pregnancy and Drugs

11. Breastfeeding Promotion Network of India

12. Not Enough Milk

13. Questions and their Answers on Breastfeeding

14. Preparation of Babys Feed

15. Questions and their Answers on Bottle Feeding

16. Jaundice in Newborn

17. Neonatal Skin Care and Diaper Dermatitis

20. Development : Physical and Mental

Mother and Child Care

21. Social, Emotional and Learning Skills

22. Help Your Child to be Physically Fit

23. Prevent Child Abuse and Neglect

25. Caloric Value of Common Foods

26. Nutrition in Pregnancy

27. Common Illnesses During First Five Years

28. Excessive Crying

29. First AID

A child is the greatest treasure of mankind. His health, well-being,

As girls grow up they become aware of their sexuality and the

Pregnancy and Baby in Womb

Mother and Child Care

Pregnancy and Baby in Womb

Mother and Child Care

Care During Pregnancy

Mother and Child Care

Tiredness during pregnancy is usual but usually there is no

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Care During Pregnancy

Mother and Child Care

Care During Pregnancy

The reduction of the strain during pregnancy is essential which is

Care of Body During Pregnancy

Mother and Child Care

Care of Body During Pregnancy

increased blood pressure. Women who learn relaxation and use it

Epilepsy and Pregnancy

The prevalence of epilepsy in general population is approximately

Epilepsy and Pregnancy

Effect on Fetus and Neonate

Diabetes Mellitus and Pregnancy

The progressive increase in insulin demand during pregnancy

Mother and Child Care

v. Increased risk of injuries to baby, and

Diabetes Mellitus and Pregnancy

Substance Abuse During

Substance abuse during pregnancy has been recognized for many

Substance Abuse During Pregnancy and Fetus

Opiate Abuse and Pregnancy

Mother and Child Care

Autonomic dysfunction Excessive sweating, mottling, hyperthermia

Low birth weight

Mother & Child Care 2003

Mother & Child Care 2003