Child health nursing

In short

Child health nursing (paediatric nursing) is the care of children from birth to adolescence - promoting healthy growth and development, preventing disease, and nursing the sick child while supporting the family. It differs from adult nursing because the child's anatomy, physiology, drug handling and emotional needs change with age, so assessment and dosage must be weight- and age-based. In India it is examined as a core INC-prescribed subject in the third/fourth year of B.Sc Nursing (theory plus clinical) and features heavily in NORCET/AIIMS, state nursing officer, ESIC, DSSSB and RRB paramedical exams. On the job it underpins work in NICU/PICU, SNCU, immunisation clinics, NRCs, paediatric wards and national programmes such as RBSK, UIP and Poshan Abhiyaan.

Explained

Scope, concepts and the Indian child-health framework

• Paediatric age groups: neonate (0-28 days; early 0-7, late 8-28), infant (<1 year), toddler (1-3), preschool (3-6), school age (6-12), adolescent (10-19).
• Philosophy: family-centred care, atraumatic care (minimise physical and psychological distress), developmentally appropriate communication, and the child's right to play and education during illness.
• Key indicators (India, SRS/NFHS-5 order of magnitude - figures are revised yearly, check the latest SRS): IMR about 26-28 per 1,000 live births, NMR about 19-20, under-five mortality about 31-32, MMR separate (maternal subject). Kerala lowest, MP/UP/Bihar highest.
• Leading causes of under-five death: prematurity and low birth weight, birth asphyxia, neonatal sepsis, pneumonia, diarrhoea, congenital anomalies; undernutrition is the underlying contributor in roughly half.
• Programmes: RMNCH+A strategy; UIP (immunisation); IMNCI / F-IMNCI; NSSK (Navjaat Shishu Suraksha Karyakram - basic newborn care and resuscitation at birth); Home Based Newborn Care (HBNC) and HBYC by ASHA; FBNC tiers - Newborn Care Corner (every delivery point), NBSU (CHC/FRU), SNCU (district hospital, 12+ beds); RBSK (child health screening for the 4 Ds - defects at birth, deficiencies, diseases, development delays including disability, 0-18 years); NRC (Nutrition Rehabilitation Centre) for SAM with complications; Mission Indradhanush / Intensified MI for full immunisation coverage; Poshan Abhiyaan, ICDS, POSHAN 2.0; Anaemia Mukt Bharat (6×6×6 strategy); National Deworming Day (albendazole, 1-19 years); School Health and Wellness Programme.
• Legal and ethical: Juvenile Justice (Care and Protection of Children) Act, 2015; POCSO Act, 2012 (mandatory reporting of child sexual offences - failure to report is punishable); RTE Act, 2009; Child Labour (Prohibition and Regulation) Amendment Act, 2016; PCPNDT Act, 1994; IMS Act (Infant Milk Substitutes, Feeding Bottles and Infant Foods Act, 1992, amended 2003) banning promotion of formula; Prohibition of Child Marriage Act, 2006; consent for a minor is from the parent/guardian (assent is taken from an older child); UNCRC rights - survival, development, protection, participation.

Growth, development and assessment

• Growth = increase in physical size (quantitative); development = maturation of function and skills (qualitative). Both are cephalocaudal, proximodistal and continuous but not uniform.
• Weight landmarks: birth weight ~2.8-3 kg (Indian average); physiological loss up to 10% in first week, regained by day 10-14; doubles by ~5 months, triples by 1 year, quadruples by 2 years.
• Length/height: birth ~50 cm; ~75 cm at 1 year; ~87-90 cm at 2 years; doubles birth length by 4 years. Head circumference: 33-35 cm at birth, ~47 cm at 1 year; chest circumference equals head circumference at about 1 year and exceeds it thereafter.
• Teeth: first temporary tooth (lower central incisor) at 6-8 months; 20 deciduous teeth by 2-2.5 years; permanent teeth from 6 years.
• Fontanelles: posterior closes by 6-8 weeks, anterior by 12-18 months. Bulging = raised ICP; sunken = dehydration.
• Milestones (gross motor): head holding 3 months, rolls over 5, sits with support 6, sits alone 8, crawls 9-10, stands with support 9, walks alone 12-15, runs 2 years, climbs stairs 2-3, hops 4, skips 5.
• Fine motor/social/language: social smile 2 months, grasp reflex gone and voluntary grasp 4-5 months, pincer grasp 9-10 months, monosyllables 6 months, 2-3 words 1 year, 2-word sentences 2 years, tells name 3 years. Stranger anxiety 6-8 months.
• Theories examined: Freud (oral, anal, phallic, latency, genital); Erikson - trust vs mistrust (infant), autonomy vs shame (toddler), initiative vs guilt (preschool), industry vs inferiority (school), identity vs role confusion (adolescent); Piaget - sensorimotor (0-2), preoperational (2-7), concrete operational (7-11), formal operational (11+); Kohlberg's moral stages.
• Assessment tools: WHO Child Growth Standards and MCP card growth chart (IAP charts for >5 years), Z-scores, mid-upper arm circumference (MUAC) tape, Denver Developmental Screening Test II / Trivandrum Development Screening Chart (TDSC - Indian), APGAR score at 1 and 5 minutes, New Ballard score for gestational age, Downe's score for respiratory distress, Silverman-Andersen score, paediatric Glasgow Coma Scale, Wong-Baker FACES and FLACC pain scales.

Newborn care and common neonatal problems

• Immediate care at birth: delayed cord clamping (1-3 min in a stable baby), dry and keep warm (skin-to-skin, cap, warm chain - prevent the four losses: conduction, convection, radiation, evaporation), early initiation of breastfeeding within 1 hour, vitamin K 1 mg IM (0.5 mg if <1 kg), identification, eye care, weight.
• Resuscitation (NSSK/NRP): if not breathing or gasping after drying/stimulation → clear airway, positive pressure ventilation with bag and mask within the Golden Minute at 40-60 breaths/min with room air for term babies; chest compressions 3:1 with ventilation if heart rate <60/min after 30 s of effective PPV; adrenaline if HR stays <60.
• Normal newborn vitals: HR 120-160/min, RR 40-60/min, axillary temperature 36.5-37.5 °C, BP ~60-80/40 mmHg systolic.
• Normal variations: milia, Mongolian spots, erythema toxicum, caput succedaneum (crosses suture lines, resolves in days) vs cephalhaematoma (does not cross sutures, resolves in weeks), physiological jaundice, pseudomenstruation, breast engorgement, epstein pearls.
• Reflexes: rooting, sucking, Moro (gone by 4-6 months), palmar grasp, plantar, tonic neck, stepping, Babinski (positive up to 1-2 years).
• LBW <2,500 g; very low <1,500 g; extremely low <1,000 g. Preterm <37 weeks; SGA = below 10th centile for gestation.
• Kangaroo Mother Care (KMC): continuous skin-to-skin contact in upright frog position, exclusive breast milk, early discharge with follow-up; for stable babies <2,000 g. Reduces hypothermia, infection, mortality; improves weight gain and bonding.
• Neonatal jaundice: physiological appears after 24 h, peaks day 3-5, bilirubin <15 mg/dL, resolves by day 10-14. Pathological - onset <24 h, rise >5 mg/dL/day, total >15 mg/dL, persists >2 weeks, or conjugated. Causes: Rh/ABO incompatibility, sepsis, G6PD deficiency, breast milk jaundice. Treatment: phototherapy (eyes and gonads shielded, frequent position change, extra fluids, monitor temperature) and exchange transfusion; kernicterus is the dreaded complication.
• Neonatal sepsis: early onset (<72 h, vertical) and late onset (hospital/community). IMNCI danger signs - not feeding well, convulsions, fast breathing ≥60/min, severe chest indrawing, movement only when stimulated or no movement, temperature ≥37.5 °C or <35.5 °C, umbilical redness extending to skin, more than 10 skin pustules.
• Others examined: respiratory distress syndrome (surfactant deficiency), transient tachypnoea, meconium aspiration, birth asphyxia and HIE, hypoglycaemia (<45 mg/dL), hypothermia, necrotising enterocolitis, ophthalmia neonatorum, retinopathy of prematurity, congenital anomalies (cleft lip/palate, tracheo-oesophageal fistula, imperforate anus, spina bifida, hydrocephalus, Down syndrome, developmental dysplasia of hip, club foot), inborn errors (hypothyroidism, PKU - newborn screening).

Nutrition, immunisation and preventive paediatrics

• Breastfeeding: exclusive for 6 months, continued to 2 years with complementary feeding from completed 6 months. Colostrum - rich in IgA, protein, vitamin A, low fat. Correct attachment - mouth wide open, chin touching breast, lower areola less visible, lower lip everted. Benefits - immunity, bonding, birth spacing, no cost.
• Complementary feeding: start at 6 months with soft mashed food, 2-3 feeds/day rising to 3-4 with snacks by 12 months; energy density, frequency, consistency, responsive feeding; avoid bottles.
• Malnutrition: SAM - weight-for-height Z-score < −3 SD, or MUAC <11.5 cm (6-59 months), or bilateral pitting oedema; MAM - WHZ between −2 and −3 SD or MUAC 11.5-12.5 cm. Marasmus (severe wasting, old-man face, no oedema), kwashiorkor (oedema, flaky-paint dermatosis, moon face, hepatomegaly, apathy), marasmic-kwashiorkor. F-75 in stabilisation and F-100/RUTF in rehabilitation; 10 steps of WHO management; treat hypoglycaemia, hypothermia, dehydration (ReSoMal), electrolytes, infection, micronutrients (no iron in stabilisation phase), cautious feeding, catch-up growth, stimulation, follow-up.
• Micronutrient deficiencies: vitamin A (night blindness, Bitot's spots, keratomalacia) - biannual vitamin A prophylaxis 9 months to 5 years; iron-deficiency anaemia - IFA syrup/tablets under Anaemia Mukt Bharat; vitamin D rickets; iodine deficiency; zinc with ORS in diarrhoea.
• Universal Immunisation Programme schedule (national schedule; states may add vaccines - verify current state schedule): Birth - BCG, OPV-0, Hepatitis B birth dose. 6, 10, 14 weeks - Pentavalent (DPT+HepB+Hib), OPV, Rotavirus, fIPV (at 6 and 14 weeks), PCV (6, 14 weeks with booster at 9 months). 9-12 months - MR/Measles-Rubella 1st dose, JE-1 (endemic districts), vitamin A 1st dose. 16-24 months - MR 2nd dose, DPT booster-1, OPV booster, JE-2. 5-6 years - DPT booster-2. 10 and 16 years - Td. Pregnant woman - Td (maternal subject). HPV vaccination for girls is being rolled out in some states.
• Cold chain: ILR +2 to +8 °C (keeps DPT, Td, HepB, PCV, rotavirus - never freeze); deep freezer −15 to −25 °C (OPV, measles stock); vaccine carrier with 4 conditioned ice packs for a session; VVM stages 1-2 usable, 3-4 discard; open-vial policy allows multi-dose liquid vaccines to be reused up to 28 days under conditions; reconstituted measles/BCG discarded in 4 hours.
• AEFI: classified as vaccine product related, quality defect, immunisation error, immunisation anxiety, coincidental; report all serious AEFI. Minor fever/swelling - paracetamol and reassurance.

Common childhood illnesses and nursing management

• Diarrhoea (IMNCI): classify dehydration - no dehydration (Plan A) home fluids, ORS, zinc 20 mg (10 mg if <6 months) for 14 days, continued feeding; some dehydration (Plan B) ORS 75 mL/kg over 4 hours; severe dehydration (Plan C) IV Ringer lactate 100 mL/kg - in infants <12 months 30 mL/kg in 1 hour then 70 mL/kg in 5 hours; in children 30 mL/kg in 30 minutes then 70 mL/kg in 2.5 hours. Low-osmolarity ORS (osmolarity ~245 mOsm/L; Na 75, glucose 75, K 20, citrate 10 mmol/L). No antidiarrhoeals or antiemetics.
• ARI/pneumonia (IMNCI): fast breathing cut-offs - ≥60/min under 2 months, ≥50/min 2-12 months, ≥40/min 12 months-5 years. Chest indrawing or any danger sign = severe pneumonia → refer, oxygen, injectable antibiotic; fast breathing alone = pneumonia → oral amoxicillin at home.
• Other infections: measles, mumps, rubella, chickenpox, diphtheria (grey pseudomembrane, antitoxin), pertussis, tetanus (neonatal tetanus), tuberculosis (paediatric TB under NTEP, weight-band daily FDC regimen), typhoid, malaria, dengue (warning signs, platelet and haematocrit monitoring), worm infestations, HIV (prevention of vertical transmission).
• Respiratory: bronchiolitis (RSV), croup, asthma (MDI with spacer in children), foreign body aspiration, cystic fibrosis (rare).
• Cardiac: cyanotic CHD - TOF (squatting, boot-shaped heart, PROVe: pulmonary stenosis, RV hypertrophy, overriding aorta, VSD), TAPVC, tricuspid atresia, transposition; acyanotic - VSD (commonest), ASD, PDA, coarctation. Rheumatic fever (Jones criteria) and RHD prevention with benzathine penicillin prophylaxis.
• Haematology/oncology: thalassemia (repeated transfusion, iron chelation), sickle cell disease, haemophilia (factor replacement, no IM injections), ITP, ALL (commonest childhood cancer), Wilms tumour (do not palpate abdomen repeatedly), retinoblastoma, neuroblastoma.
• Renal/GI: nephrotic syndrome (massive proteinuria, hypoalbuminaemia, oedema, hyperlipidaemia; steroids), acute glomerulonephritis (post-streptococcal, haematuria, hypertension), UTI, intussusception (red-currant jelly stool), pyloric stenosis (projectile non-bilious vomiting, olive mass), hernia.
• Neuro: febrile convulsion (6 months-5 years, simple vs complex), epilepsy, meningitis, cerebral palsy, hydrocephalus (VP shunt care), neural tube defects, autism and ADHD screening.
• Emergency and ward skills: paediatric BLS (compression:ventilation 15:2 with two rescuers, 30:2 single rescuer, depth one-third chest, 100-120/min), oxygen delivery, nebulisation, suctioning, nasogastric feeding, burns fluid calculation, poisoning and ingestion, child abuse recognition, restraints (mummy, elbow, clove-hitch), play therapy, isolation and infection control, hospitalisation reactions (protest, despair, detachment - Bowlby's separation anxiety), preparation for procedures, discharge teaching.

Key points

• Paediatric age bands - neonate 0-28 d, infant <1 y, toddler 1-3, preschool 3-6, school 6-12, adolescent 10-19.
• Weight rule - doubles at 5 months, triples at 1 year, quadruples at 2 years; 10% physiological loss regained by day 14.
• Head vs chest circumference - equal at about 1 year; HC 33-35 cm at birth, ~47 cm at 1 year.
• APGAR - HR, respiration, muscle tone, reflex irritability, colour; each 0-2; 7-10 normal, 4-6 moderate, 0-3 severe asphyxia; scored at 1 and 5 minutes, never used to decide whether to start resuscitation.
• Golden Minute - effective bag-and-mask ventilation must begin within 60 seconds of birth in a non-breathing baby.
• KMC - skin-to-skin for stable babies under 2,000 g; cuts hypothermia, sepsis and mortality.
• Physiological vs pathological jaundice - appearing after 24 h and under 15 mg/dL is physiological; onset within 24 h is always pathological.
• Breastfeeding - exclusive 6 months, initiate within 1 hour, continue to 2 years; colostrum is the first immunisation.
• SAM criteria - WHZ < −3 SD, MUAC <11.5 cm, or bilateral pitting oedema; F-75 then F-100/RUTF; no iron in the stabilisation phase.
• ORS - low-osmolarity 245 mOsm/L plus zinc for 14 days is the cornerstone; Plan A/B/C by dehydration grade.
• IMNCI fast-breathing cut-offs - 60/50/40 per minute for <2 months, 2-12 months, 1-5 years.
• UIP - BCG, OPV-0, HepB at birth; pentavalent/OPV/rota/fIPV/PCV in infancy; MR at 9 months and 16-24 months; Td at 10 and 16 years.
• Cold chain - ILR +2 to +8 °C, deep freezer −15 to −25 °C; discard a vaccine at VVM stage 3 or 4; never freeze DPT, Td or HepB.
• Paediatric drug dosing - by body weight (mg/kg) or body surface area; BSA is preferred for cytotoxics.
• Fluid maintenance - Holliday-Segar 100/50/20 mL/kg/day for the first 10, next 10 and remaining kg.
• Dehydration in children - mild 5%, moderate 10%, severe 15% of body weight (infants); sunken fontanelle and skin turgor are key signs.
• Hospitalised child - separation anxiety passes through protest, despair and detachment; play therapy and parental presence are therapeutic, not optional.
• Legal duty - POCSO, 2012 makes reporting suspected child sexual abuse mandatory; JJ Act, 2015 governs care and protection.

Formulas and examples

• Expected weight and height: a healthy child of 4 years → weight = (4 × 2) + 8 = 16 kg; height = (4 × 6) + 77 = 101 cm. A 9-month-old → (9 + 9)/2 = 9 kg.
• Maintenance fluid and drip rate: a 26 kg child needs maintenance IV fluid.
  • First 10 kg → 10 × 100 = 1,000 mL; next 10 kg → 10 × 50 = 500 mL; remaining 6 kg → 6 × 20 = 120 mL.
  • Total = 1,620 mL/day ≈ 67.5 mL/hour.
  • With a microdrip set (60 drops/mL): 67.5 × 60/60 = 67-68 drops/min (microdrops/min equal mL/hour).
• Plan C severe dehydration: a 7-month-old infant weighing 6 kg with severe dehydration, Ringer lactate 100 mL/kg.
  • Total = 6 × 100 = 600 mL. Infant schedule: 30 mL/kg = 180 mL in the first hour, then 70 mL/kg = 420 mL over the next 5 hours.
  • First-hour rate = 180 mL/h = 180 microdrops/min; next 5 hours = 420/5 = 84 mL/h. Reassess every 15-30 min; give ORS 5 mL/kg/h as soon as the child can drink.
• Plan B some dehydration: a 10 kg toddler → ORS 75 mL/kg = 750 mL over 4 hours (about 187 mL/hour, given by spoon/cup), plus zinc 20 mg daily for 14 days and continued feeding.
• Paediatric dose by weight and by BSA: amoxicillin 40 mg/kg/day in 3 divided doses for a 12 kg child → 480 mg/day → 160 mg per dose 8-hourly; with a 125 mg/5 mL syrup that is 160/125 × 5 = 6.4 mL per dose.
  • BSA check for a child 100 cm, 16 kg: BSA = √(100 × 16/3600) = √0.4444 = 0.667 m². If the adult dose is 300 mg, child dose = 300 × 0.667/1.73 ≈ 116 mg.
• Fluid deficit: a 12 kg child with 10% dehydration → deficit = 10 × 12 × 10 = 1,200 mL, replaced along with maintenance (12 kg → 1,000 + 100 = 1,100 mL/day) over 24 hours as prescribed.

Where it is used

• Hospital paediatrics: staff nurse roles in NICU, SNCU, PICU, paediatric wards and paediatric OT at AIIMS, PGIMER, CMC Vellore, state medical colleges, and Apollo/Fortis/Rainbow/Cloudnine private chains.
• Government programmes: nursing officers and community health officers delivering UIP sessions, VHND, HBNC supervision, RBSK screening teams, NRC and school health programmes under NHM.
• Competitive exams and teaching: NORCET (AIIMS), ESIC, DSSSB, RRB, state Nursing Officer and military nursing exams; nursing tutor posts in INC-recognised colleges; NCLEX/CGFNS for abroad.
• Industry and products: vaccine cold-chain and immunisation logistics, paediatric medical devices (radiant warmers, phototherapy units, CPAP), infant nutrition and RUTF supply, paediatric pharmacovigilance and AEFI surveillance.
• NGO and research: UNICEF, WHO India, PATH, Jhpiego, Save the Children; clinical research coordinators in paediatric trials; IMNCI and NSSK trainers.
• Community practice: anganwadi and ASHA support, growth monitoring and counselling, adolescent health clinics (RKSK), home-based care of children with disability.

Interview questions

• Q: What does APGAR assess and when is it scored? A: Heart rate, respiratory effort, muscle tone, reflex irritability and colour, each 0-2, at 1 and 5 minutes; 7-10 is normal. It documents transition but resuscitation is never delayed to score it.
• Q: How do you differentiate physiological from pathological neonatal jaundice? A: Physiological appears after 24 hours, peaks on day 3-5, stays below about 15 mg/dL and resolves in 10-14 days; onset within 24 hours, a rise over 5 mg/dL/day, conjugated bilirubin or persistence beyond 2 weeks is pathological.
• Q: A 6 kg infant has severe dehydration - what is your immediate plan? A: IMNCI Plan C: Ringer lactate 100 mL/kg - 30 mL/kg (180 mL) in the first hour, then 70 mL/kg (420 mL) over 5 hours, reassess every 15-30 minutes, start ORS when the child can drink, add zinc and continue feeding.
• Q: Why is zinc given in childhood diarrhoea? A: Zinc 20 mg daily (10 mg under 6 months) for 14 days shortens the episode, reduces stool volume and lowers the risk of diarrhoea in the next 2-3 months by restoring gut mucosal integrity and immunity.
• Q: Which vaccines must never be frozen, and how do you check a vial's usability? A: DPT/pentavalent, Td, hepatitis B, PCV, IPV and rotavirus - freezing destroys the adjuvanted vaccines. Check the vaccine vial monitor: stages 1 and 2 are usable, 3 and 4 must be discarded.
• Q: Define SAM and state how you would start feeding. A: Weight-for-height Z-score below −3 SD, MUAC under 11.5 cm in 6-59 months, or bilateral pitting oedema. Start F-75 in the stabilisation phase with small frequent feeds, correcting hypoglycaemia, hypothermia, dehydration and infection, then move to F-100 or RUTF for catch-up growth.
• Q: What is Kangaroo Mother Care and who is eligible? A: Continuous skin-to-skin contact of a stable low-birth-weight baby (usually under 2,000 g) on the mother's chest with exclusive breast milk and early discharge; it prevents hypothermia and infection and improves weight gain and survival.
• Q: How do you recognise pneumonia in a 10-month-old using IMNCI? A: Count breathing for a full minute - 50 or more per minute is fast breathing (pneumonia, treat with oral amoxicillin at home); chest indrawing or any danger sign means severe pneumonia needing referral, oxygen and injectable antibiotics.
• Q: Why is a child's drug dose calculated by weight or body surface area rather than age? A: Children vary widely in weight at the same age and their absorption, distribution, hepatic metabolism and renal clearance differ; mg/kg is standard and BSA is used for narrow-margin drugs such as cytotoxics.
• Q: What are the IMNCI danger signs in a young infant? A: Not feeding well, convulsions, fast breathing 60/min or more, severe chest indrawing, movement only on stimulation or none, temperature 37.5 °C or above or below 35.5 °C, umbilical redness spreading to the skin, and more than 10 skin pustules - all require urgent referral.
• Q: A 3-year-old screams and clings when the parent leaves the ward. How do you respond? A: This is the protest stage of separation anxiety; allow parental rooming-in and a familiar object, keep routines, assign consistent nurses, use play therapy and never shame the child or restrain for convenience.
• Q: You suspect a child in your ward has been sexually abused. What is your obligation? A: POCSO, 2012 makes reporting mandatory - inform the designated authority or police through the hospital's protocol, document findings objectively, preserve evidence, maintain confidentiality and ensure the child is not re-examined repeatedly; failure to report is itself an offence.

Common mistakes

• Mixing up Plan B and Plan C volumes, or giving the infant Plan C schedule (1 h + 5 h) to an older child (30 min + 2.5 h).
• Applying the Holliday-Segar rule to total body weight instead of in 10 + 10 + remaining bands.
• Using age-based rules (Young's, Fried's) when the child's weight is available - weight or BSA is correct practice.
• Calling jaundice on day 1 "physiological", or stopping breastfeeding during phototherapy.
• Forgetting the full-minute respiratory count and the age-specific IMNCI cut-off, so pneumonia is missed or over-diagnosed.
• Giving iron during the stabilisation phase of SAM, or starting high-energy feeds before hypoglycaemia, hypothermia and infection are corrected.
• Freezing DPT/hepatitis B, reusing reconstituted BCG or measles beyond 4 hours, or quoting an outdated UIP schedule without checking the state's current one.

Related topics

• Maternal and obstetric nursing · Community health nursing · Nutrition and dietetics · Medical-surgical nursing · Pharmacology and dosage calculation · Nursing management of emergencies and critical care.