Introduction:

There is a famous saying, “healthy children contribute to healthy nation”. Prevention is the best
measure to maintain health, an old saying, “a stich in time saves nine” supports this. Child survival
strategies are extremely important to tackle current problems of on malnutrition, infection,
diarrheal disease and poor maternal health. The approach should be based on low-cost
interventions acceptable to the people.
Definition:
Preventive Pediatrics is defined as the prevention of illness and promotion of physical, mental and social well-
being of children with the aim of attaining an optimum health status.
Aims:
• Preventive pediatrics aims at the prevention of disease in children rather than focusing on
cure of disease.
• By preventing disease, the child can attain its genetic potential.
Components:
a) Health education
b) Growth monitoring
c) Promotion of breast feeding
d) Oral rehydration
e) Regular health Checkup

f) Nutritional surveillance

g) Immunization

A) Health Education:
Health education to the mother is an essential and compulsory activity of the under-five’s clinic. The mothers
should receive the information on various aspects of child care and child rearing practices.
o Preventive measures against malnutrition, ARI, diarrhea tuberculosis, worm infestations, etc. should be
informed to the mothers to improve awareness about the disease and its prevention.
o The under-fives clinic is usually located in village or a slum or a labor colony. It is managed by trained
health worker.
o She also visits home to educate the mothers and to make sure that children are brought to the clinic for
regular check-up.
o She maintains child registers and records related to child care given and health check-up done. She
distributes supplementary food, vitamin 'A' oil and iron-folic acid tablets and keep accounts of
expenditure.
o She arranges health exhibitions, well-baby competitions and mother craft training program. Thus,
'under- fives' clinics provide a low- cost comprehensive care through preventive promotive, curative and
rehabilitative health care services to the under- five children.
 B) Growth monitoring: Periodically height and weight of every child has to be recorded on
the growth chart of healthcare professional, which will help to detect early onset of growth
failure and its cause, remedial measures will be followed.
Weighing of the child at regular intervals, the plotting of that weight on a graph (called
a growth chart) enabling one to see changes in weight, and giving advice to the mother based
on this weight change is called 'GROWTH MONITORING. It should be done once every
month, up to age of 3 years and at least once in 3 months, thereafter.
Methods of Growth Monitoring:
Weight for Age:
Single best parameter for assessing physical growth. Careful repeated measurement at intervals, ideally from
birth-1 month weekly, one month-3 years every month and 3-5 years at every three months is very important.
Height (Length) for age:
Height should be taken in a standing position without footwear with the help. of height machine or measuring
scale fixed to the wall. Suitable for children 2 years or above. The length of the baby at birth is about 50 cm.
It increases by about 25 cm during first year and by another 12 cm during the second year. Height is a stable
measurement of growth as opposed to body weight.
Weight for Height:
Weight and Height are interrelated. If there is low weight for height, it is called as nutritional wasting or
emaciation (acute malnutrition). A child less than 70 percent of the expected weight for height is classed as
severely wasted.

C)Promotion of breastfeeding: Breast milk is the best food available and is tailor- made to
suit the child’s needs. Breast feed babies get the most notoriously balanced diet and susceptible
to infections. Exclusive breastfeeding id essential for the healthy growth of the child.
✓ Positions of breastfeeding:
❖ Correct vs incorrect:
Proper position of baby while breastfeeding includes –
-Supporting whole of baby's body.
-Ensure baby's head, neck, and back are in same plane.
- Entire baby's body should face mother, -Baby's abdomen touches mother's abdomen.
❖ Side lying position:
This allows mothers to rest or sleep while baby nurses, especially who have had caesarean
births-
-Mother lies on her side using pillows under head and back.
- Head and neck should be comfortably propped up.
- Put a small rolled blanket behind the baby's back.
- Pull baby close and guide his/her mouth to the nipple.
❖ Cradle position:
This is a commonly used comfortable position-
- Mother holds her baby with his head on her forearm and his/her whole body facing her.
- Place baby across her stomach, with her face and knees close-in facing mothers body.
❖ Cross cradle position:
This is good for premature babies or babies who are having trouble latching on -
- Mother holds her baby along the opposite arm from the breast she is using.
- Support baby's head with the palm of her hand at the base of his/her head.
❖ Clutch or football position:
Good for mothers with large breasts or inverted nipples -
- Mother holds her baby at her side, lying on his/her back, with his/her head at the level of
your nipple.
- Support baby's head with the palm of mother's hand at the base of his/her head.
❖ Twin football or clutch position:
Nursing in football/ clutch hold is common for twins –
- Each baby is nursing while his stomach wraps around mother's and feet extend
around her body to the side.
- With supportive pillows underneath babies, it is easy to use her hands to help
babies latch.
❖ Twin cross cradle position:
- Support one baby's head in each of mother's arms.
- Babies' heads may rest in the bend of her arm near her elbow.
- Babies' bodies will be in her lap turned toward her abdomen.
❖ Football and cradle hold combination:
- Mother holds one baby using the football hold and the other baby using the cradle
hold.
➢ Advantages of breastfeeding:
- Nutritive Value: Breast milk contains all the nutrients in the right proportion
which are needed for optimum growth and development of the baby up to 6
months.
- It is essential for brain growth and It facilitates absorption of calcium which helps
in bony growth.
- Breast milk fats are polyunsaturated fatty acids which are necessary for the
myelination of the nervous system.
- It has vitamins, minerals, electrolytes and water in the right proportion for the
infant which are necessary for the maturation of the intestinal tract.
- Digestibility: Breast milk is easily digestible. The protein of breast milk are
mostly lactoalbumin and lactoglobulin which form a soft curds that is easy to
digest.
 - Breast milk contains IgA, IgM, macrophages, lymphocytes, bifidus factors,
unsaturated lactoferrin, lysozyme, complement and interferon and thus body less
likely to develop infections.

- Exclusive breastfeeding baby has less chance of developing malnutrition,

hypertension, diabetes mellitus, coronary artery disease, arteriosclerosis,
ulcerative colitis, appendicitis, childhood lymphoma, liver disease; celiac disease
and dental caries.
- Psychological Benefits: Breastfeeding promotes close physical and emotional
bondage with the mother by frequent skin to skin contact, attention and
interaction.

✓ Human milk bank:

Definition: A human milk bank is a service established for collecting, screening, processing,
storing and distributing donated human milk.
History: Donation of breast milk from one woman to an unrelated infant has a long history.
Before this century, the infant would have been directly breastfed by the woman who was
referred to as a 'wet nurse'. Rules governing wet-nursing have been around since 1800 BC.
Human milk banking has had similar peaks and troughs. In the early half of this century, milk
banking saw resurgence in popularity, but around the 1970s, this began to change.
International Statement: WHO and UNICEF, made a joint statement in 1980; "where it is
not possible for the biological mother to breastfeed, the first alternative, if available, should be
the use of human milk from other sources. Human milk banks should be made available in
appropriate situations".
Uses: Banked human milk is regarded as 'the next best' after the biological mother's breast
milk. It is used for the treatment of many conditions [(mainly in Neonatal Intensive Care Units
NICUS)] prematurity, malabsorption, short-gut syndrome, intractable diarrhea, nephrotic
syndrome, some congenital anomalies, formula intolerance, failure to thrive, immune
deficiencies (igA).
Studies have found that breast milk has a protective effect against necrotizing enterocolitis
(NEC). Lucas and Cole found that NEC was 6-10 times more likely to develop in exclusively
formula fed infants than in those fed only breast milk, and that NEC was three times more
likely when formula-only fed infants were compared to those receiving both breast milk and
formula. Other studies have demonstrated that formula fed infants had lower IQ scores than
infants fed breast milk.
Milk banks vary in their use of banked milk. In some cases, milk is provided for adopted babies
or older children with severe food allergies.
In 1988, 72% of the milk dispensed from all the milk banks in the USA was prescribed for
infants in neonatal intensive care units, 23% went to babies at home and 2% was used for
pediatric inpatients.
Screening: One of the major issues milk banking faces is the possibility of transmission of an
infectious disease via the milk. Parents may fear accepting donated milk for this reason, while
doctors may feel that the benefits of donated milk are outweighed by the possible legal
implications. Consequently, screening is extremely important. A system of 'triple protection' is
applied:
- Review of donor's health history
- Serum screening
- Heat treatment of all donor breast milk.
Donors are educated regarding the most hygienic way to express milk. Hand expression is the
best method for collection; however, some centers will allow certain types of hand pumps to
be used. Drip milk (milk that drips from the unused breast during feeding or expressing from
the other breast) has a lower caloric content and is more susceptible to contamination, but is
acceptable to some centers.
The type of container used for collection also varies according to what is most readily available.
Polythene bags are associated with a decrease in the IgA content of milk, while glass is linked
to a loss of leukocytes. The current recommendation is that glass is best, but worldwide many
different types of materials are used. In India steel utensils/ containers are used.
Controls/Pasteurization: Most milk banks do bacterial counts on each donor's milk before
pasteurization, as pasteurization, may be ineffective if the milk is heavily contaminated with
microorganisms. There are no set levels for colony count levels, but it is an example one center
uses the following:
- <103 colony-forming units-milk is used
- 105 colony-forming units-milk is not used
- 103-105-forming units-milk is only used if organisms are skin commensals.
Storage: The American milk bank guidelines give clear recommendations regarding these
practical issues. Fresh- raw milk must be stored continually at 4°C for no longer that 72 hours
following expression, whereas fresh-frozen milk can be held at 20°C for 12 months. Heat-
treated (pasteurized) milk may be stored under the same conditions as fresh milk.

D) Oral rehydration: To prevent child’s mortality due to diarrheal disease, ORT has to be
supplemented in mild dehydration cases itself. Oral rehydration solution (ORS) is an oral
powder that contains a mixture of: Sodium chloride, Potassium chloride, Sodium citrate.
ORS is intended for the prevention and treatment of dehydration due to diarrhea, including
maintenance therapy. It is composed of iso‐osmolar glucose electrolyte solution with base and
citrate.
The ingredients for ORS are:
Sodium chloride - 3.5 grams
Trisodium citrate dihydrate - 2.9 grams Potassium chloride - 1.5 grams
You can also make ORS at home:
Clean water – 1 liter – 5 cupful (each cup about 200 ml.)
Sugar – Six level teaspoons Salt – Half level
teaspoon
Stir the mixture till the sugar dissolves source.
✓ Baby friendly hospital initiative:
The Baby-friendly Hospital Initiative (BFHI) was launched by World Health Organization
(WHO) and United Nations Children's Fund (UNICEF) in 1991, following the Innocenti
Declaration of 1990. This is a global effort to implement practices that protect, promote and
support breastfeeding.
1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
2. Train all healthcare staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within half an hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation, even if they should be separated from their
infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in-allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifier like dummies or soothers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mother to them on discharge from the
hospital or clinic.
Indian hospitals are still in early stages of joining this movement. The National
BFHI task force was formed in 1992, towards the efforts to improve the breastfeeding practices. The task
force comprising Government of India, UNICEF, WHO and professional organizations (TNAI, BPNI, NNF,
IMA, FOGSI, IAP, CMAI, CHAT, IBFAN, ACASH) is working children for evaluation of breastfeeding
practices in the hospitals and appropriate certification as 'Baby Friendly Hospital.
Besides promotion of breastfeeding, baby friendly years. hospital initiative in India also proposes to
provide:
- Improved antenatal care
- Mother friendly delivery services
- Standardized institutional support
- Diarrhea management
- Promotion of healthy growth and good nutrition
Aims of BFHI:
• To initiate global assessment and accreditation.
• To enable the mother to acquire the skills needed for breastfeeding.
• To assist the mothers who are not breastfeeding.
• To implement BFHI in the curriculum for the health worker.
Revised Package of BFHI:
The revised package of BFHI materials includes five sections:
1. Background and implementation.
2. Strengthening and sustaining the BFHI: A course for decision-makers.
3. Breastfeeding promotion and support in a baby-friend hospital: A 20-hour course for
maternity staff.
4. Hospital self-appraisal and monitoring.
5. External assessment and reassessment

✓ Under five clinics:

The children under 5 years of age constitute about 15% of the total population. They suffer high rates of
mortality and morbidity. The effects of malnutrition and other diseases at this age may have a role in later life.
The majority of the deaths are preventable through available interventions. Under-five clinic is a center,
where preventive, promotive, curative, referral and educational services are provided in a package manner to
under five children under one roof.
 Goal:
The overall goal of the under-five clinic is to provide the comprehensive health care to young children in a
separate specialized setting.
The under-five clinic is represented by traditional logo of a triangle with four internal triangles and an outer
enveloping triangle. The apex of the large triangle represents the care in illness, the left triangle denotes growth
monitoring, the right triangle indicates preventive care and the central red triangle indicates family planning.
The outer enveloping triangle proposes health education in all four triangles inside.
Components:
• Care in illness: This is the felt need of the mother and child for which any child is brought to the clinic.
Services includes:
• Growth monitoring
• Preventive care
• Family planning
• Health education
Functions of Well-baby Clinic:
• Primary immunizations for childhood diseases such as diphtheria, pertussis, tetanus, polio, Haemophilus
influenzae type B, hepatitis B, measles, mumps, rubella, and varicella.
• Tracking immunization rates in the community and notifying families when shots are due.
• Growth assessments: Length, weight & head circumference measurements should be taken with each visit.
These measurements are plotted on growth charts and are compared to detect developmental delay.
• Assessments of the baby's reflexes and neurological developments.
• Systemic examinations to detect any childhood diseases from earlier stages.
• Screening eyes for vision abnormalities and muscle imbalance, the ears for infection, the heart for murmurs,
and the hips for developmental dysplasia.

• Testing for anemia and lead poisoning.

• Family education especially on breastfeeding & good nutrition.
-Infants are initially assessed at two weeks of age. Subsequent visits are at 2, 4, 6, 9, and 12 months.
-Toddlers and preschoolers are seen at 15 months, 18 months, and then yearly at 2, 3, 4, 5, and 6 years. School-
age children are routinely evaluated every one to two years for school and camp.
- Teenagers are screened for sports participation and work permits. They are also counseled on age-appropriate
issues such as drug and alcohol abuse, prevention of sexually transmitted diseases and the hazards of smoking.
E) Immunization: Primary & booster doses of vaccination will be given against six killer
diseases for under five children to achieve full immunization status.
Mission Indhradhanush:
The Government of India's recent initiative "Mission Indradhanush" launched on December
25, 2014, has concentrated on providing infant immunization in districts with poor vaccination
coverage. Vaccination was given against eight vaccine preventable diseases nationally, i.e.
Diphtheria, Pertussis, Tetanus, Polio, Measles, severe form of Childhood Tuberculosis and
Hepatitis B and Hemophilus influenza type B.
Intensified Mission Indradhanush: To further intensify the immunization programme, the
Intensified Mission Indradhanush (IMI) was launched on October 8, 2017.
The focus of special drive was to improve immunization coverage in select districts and
cities to ensure full immunization to more than 90% by December 2018.
Under IMI, four consecutive immunization rounds were conducted for 7 days in 173 districts
(121 districts and 17 cities in 16 states and 52 districts in 8 north- eastern states) every month
between October 2017 and January 2018.
To boost the routine immunization coverage in the country, Government of India has
introduced Intensified Mission Indradhanush 2.0 to ensure reaching the unreached with all
districts and blocks from December 2019-March 2020.
Goals and targets:
Measles vaccine introduces in India Through UIP in 1974 in two doses.

Reduced incidence of measles cases but national coverage below 95% for elimination plan

In 2014, WHO Strategic Plan sets goal to eliminate Measles by 2020

In 2014, NTAGI, recommends introduction of MR vaccine in routine immunization program

following a national MR campaign

IN 2017, MR campaign rolled out targeting children between 9 months and 15 years
irrespective of previous vaccination status to improve the national vaccine coverage to 95%
along with MR surveillance.
Vaccines of Mission Indhradhanush:

Birth BCG, Hep B1, OPV

6 weeks DTwP /DTaP1, Hib-1, IPV-1, Hep B2, PCV

1,Rota-1
10 weeks DTwP /DTaP2, Hib-2, IPV-2, Hep B3, PCV 2,
Rota-2
14Weeks DTwP /DTaP3, Hib-3, IPV-3, Hep B4, PCV 3,
Rota-3*
6 Months Influenza-1

7 Months Influenza -2

6 – 9 Months Typhoid Conjugate Vaccine

9 Months MMR 1 (Mumps, measles, Rubella)

12 Months Hepatitis A- 1

12 – 15 Months PCV Booster

15 Months MMR 2, Varicella

16 – 18 Months DTwP /DTaP, Hib, IPV

18 – 19 Months Hepatitis A- 2**, Varicella 2

4 – 6 years DTwP /DTaP, IPV, MMR 3

9 – 15years (Girls) HPV (2 doses)

10 – 12 Years Tdap/ Td

2nd, 3rd, 4th and 5th Year Annual Influenza Vaccine

 BCG: Bacillus Calmette‐Guerin; DPT: diphtheria‐pertussis‐tetanus; Hep B: Hepatitis B; Hib:

Hemophilus influenzae type b; JE: Japanese Encephalitis; MCV: measles alone or MR/MMR; OPV:
oral polio vaccine; TT: tetanus toxoid; IPV: inactivated poliovirus vaccine; RVV: Rotavirus vaccine.

o Measles supplementary immunization activity: Measles is a very contagious disease caused by an

RNA Paramyxo virus. One of the most common and notorious complications f of measles infection is
pneumonia. Though measles vaccine its role in the prevention and control of pneumonia cannot be
overlooked since one of the common complications of measles is pneumonia.
In India, measles vaccine is given as two doses (firs dose at nine months of age and second
dose between 18 months and 24 months of age). Despite great efforts to achieve immunization coverage
to all under five children in India, the immunization coverage has not reached the expected coverage
levels in the last few years.
With a view to combat various vaccine preventable diseases in a comprehensive way and also
to achieve a maximum immunization coverage of more than 95% of children, Government of India
introduced two initiatives namely:
- Pentavalent vaccine
 - Measles rubella vaccine campaigns the burden of pneumonia due Hemophilus influenza type b can be
reduced by Pentavalent vaccine (DPT+ Hep B + HiB) which was introduced in India in phased manner.
Pentavalent vaccine is given as a deep intramuscular injection in the anterolateral aspect of the thigh at 6, 10,
and 14 weeks after birth. It should be stored between +2°C to+8°C and are to be kept in the basket of ice lined
refrigerator (ILR).

o Polio Eradication and Pulse Polio Immunization: The Pulse Polio Initiative was started with an
objective of achieving hundred per cent coverage under Oral Polio Vaccine. It aimed to immunize
children through improved social mobilization, plan mop-up operations in areas where poliovirus has
almost disappeared and maintain high level of morale among the public.
- In 1985, the UNIVERSAL IMMUNISATION PROGRAM (UIP) was launched to cover all the districts
of the country. UIP became a part of child survival and safe motherhood program (CSSM) in 1992 and
Reproductive and Child Health Program (RCH) in 1997. This program led to a significant increase in
coverage, up to 5%. The number of reported cases of polio also declined from thousands during 1987 to
42 in 2010.

- In 1995, following the Global Polio Eradication Initiative of the World Health Organization (1988), India
launched Pulse Polio immunization program with Universal Immunization Program which aimed at
100% coverage.

- The last reported cases of wild polio in India were in West Bengal and Gujarat on 13 January 2011. On
27 March 2014, WORLD HEALTH ORGANISATION (WHO) declared India a polio free country, since
no cases of wild polio been reported in for five years.

F) Nutritional surveillance: To identify subclinical nutritional deficiency disorders ‘Road to

health chart’ has to be maintained. If any children were identified as malnourished, food has to be
supplemented (ICDS, Anganwadi workers) to overcome malnutrition.
o Weaning: The word ‘wean’ means accustom. Weaning is the process by which infant
gradually accustom to milk. Complementary feeding or weaning is after 6 months of age
to ensure optimum growth and pre malnutrition.
The breast milk in reasonable quantities alone cannot meet all the energy and protein requirement
for maintain of 4-6 months. It is, therefore, necessary to introduce more concentrated nutritional
supplements beyond this age.
Developmental changes indicating infant's readiness tolerate complementary foods:
• The infant's intestinal tract develops immunologically with defense mechanisms to protect the
infant from foreign proteins.
• Ability to digest and absorb proteins, fats, and carbohydrates other than those in breast milk and
formula, increase rapidly.
• Kidneys acquire the ability to excrete the waste products from foods with a high renal solute load.
• Infant develops the neuromuscular mechanism responsible for recognizing and accepting a spoon
masticating, swallowing nonliquid foods, and appreciating various taste and color of foods.
Weaning before 4 months is called early and after 9 month is called late weaning.
Stages:
Stage 1: This lasts for one month starting from 6 month. At this stage, a small amount of food,
such as cereal gruel followed by a basic mix, is introduced and the food is given after the
breastfeeding.
Stage 2: In this stage, the weaning foods are gradually in increasing quantity, switching to the
multimix along with the breastfeeding. The aims are to accustom the child to the family foods by
the first birth/day.
Stage 3: There is decreasing amount of breast milk from partial to token breastfeeding with
increasing amount of family foods, ultimately to a meal to complete weaning.
Principles:
✓ Introduce new foods one at a time.
✓ Introduce single-ingredient food initially to determine the infant's acceptance to each food
(e.g., try plain rice cereal before rice cereal mixed with fruit).
✓ Keep interval of at least 7 days between the introduction of each new "single-ingredient" food.
✓ Introduce a small amount (e.g., about 1-2 teaspoons) of a new food at first (this allows an infant
to adapt to a food's flavor and texture).
✓ Observe the infant closely for adverse reactions such as rash, wheezing, or diarrhea after
feeding a new food. Gradually increase the frequency and quantity.
✓ Use spoon initially and encourage handling the food and encouraging feed himself.
✓ During the first year give the breastfeeding first and during the second year give the
complementary foods first.
✓ No forceful feeding is advised.

Frequency of Complementary Feeding: Initially give 1-2 times a day in small amount and
gradually increase 3-4 times daily along with breastfeeding. After one year, food should be given
4-5 times daily with night time breastfeeding.
Types of Complementary Food:
Stage 1:
• Breast milk 600 mL/day.
• Starchy food-cereal such as rice, wheat.
• Mashed, pureed and starchy vegetable like potato, carrot.
• Fruit juice not before 6 months and should be freshly prepared or 100% fruit juice.
• Soft cooked and pureed vegetables and fruits-apple, banana, mango.
• Nonfibrous vegetables like cauliflower, pureed spinach.
• Food should not be sweetened and salted.
Stage II:
• Gradually increase the amount and frequency
• Continue breastfeeding.
• Starchy foods 2-3 servings: Wheat-based cereal khichri, sooji-halwa porridge, raggi mixed with
milk.
• Vegetable 2 servings: Soft cooked carrot, green beans, stewed apple, spinach or tomato soup.
• Egg yolk/cheese: 1 serving.
• Try crackers, bread, noodles, macaroni, and other grain products like plain ground or mashed rice
or barley, noodles, plain enriched or whole grain crackers, preferably low in salt; small pieces of
toast or crust of bread.
Stage III:
• Continue breastfeeding.
• Starchy foods: 3-4 servings.
• Vegetable and fruits: 3-4 servings, raw or chopped finger food.
• Fish and minced meat: 1 serving.
• Sample menu for complementary feeding.
• Breakfast: Raggi/rice khir, suji halwa, stewed apple with curd, boiled egg and bread finger.
• Lunch: Khichri, mixed vegetable soup, rice with curd.
• Dinner: Same as lunch.
o Supplementary Food:
Infant food mixes can be made at home from food grains available in the household. These
mixes can be stored at least for a month and enable frequent feeding of infants.
These are sattu-like preparations, which is quite familiar in the Indian community.
One can take three parts of any cereal (rice/ or millet (ragi, bajra or jowar), one part of any pulse
(moong/channa/arhar) and half part of groundnuts or white til, if available.
The food items should be roasted separately, ground, mixed properly and stored in
airtight containers. For feeding, take two tablespoon of this infant food mix, add boiled hot
water or milk, sugar or jagerry and oil/ghee and wheat) mix well.
o Formula Preparation: Steps:
1. Step 1: Fill up the kettle with fresh water: Use at least 1 liter of fresh tap water. Don’t
boil and use water that has already been boiled, or use artificially-softened water. Bottled
water is also not recommended for making up a feed as it’s not sterile and may contain
too much salt (sodium) or sulphate
2. Step 2: Boil the water: Then leave it to cool for up to 30 minutes, so that it has cooled
but is still at least 70°C.
3. Step 3: Clean area and wash your hands: It's important to disinfect the surface you are
going to use and wash your hands thoroughly.
4. Step 4: Rinse and shake excess water: If you’re using a cold-water sterilizer, shake off
any excess solution from the bottle and the teat, or rinse them with cooled boiled water
from the kettle (not tap water). Then put your sterilized baby bottle on the cleaned,
disinfected surface.
5. Step 5: Pour the water in: Use the amount of water you need and double check the water
level is correct. Always put water in the bottle first, while it’s still hot, before adding any
powdered formula.
6. Step 6: Loosely fill the scoop with formula powder: Do this according to the
manufacturer's instructions. Level it off using either the flat edge of a clean, dry knife or
the leveler provided. Different tins of formula come with different scoops. Make sure you
only use the scoop that comes with the formula.
7. Step 7: Put the teat back on the bottle: Holding the edge of the teat, put it on the bottle.
Then screw the retaining ring onto the bottle. Cover the teat with the cap and shake the
bottle until all of the formula powder dissolves.
8. Step 8: Cool the bottle for your baby: It's important to cool the formula so it's not too
hot to drink. You can do this by holding the bottle (with the lid on) under cold running
water.
 9. Step 9: Test the temperature: Always test the temperature of the formula on the inside
of your wrist before feeding it to your baby. It should be body temperature, which means
it feels warm or cool, but not hot.
10. Step 10: Throw away un-used feed: If there is any made-up formula left after your baby
has finished feeding, always throw it away.

G) Regular health checkup: Growth monitoring and periodic health checkup id necessary for
ensuring good health. American Academy of Pediatrics recommends for well child visit at
following intervals:
Infancy (Newborn to <9 months): Every newborn should be shown in the first
week of discharge, ideally at 3-5 days and then at one month. Most important issues to
address weight, jaundice, breastfeeding. Next visit may be done at 2,4,6,9 month of age.
Early childhood (12 month to 4 years): Visit is recommended at 12,15,18,24 &
rd th
30 months old, then yearly in 3 and 4 year.
Middle childhood to adolescence: Once in a year regular health check up
should include anthropometric measurements; sensory screening, developmental/
behavioral screening, physical examination, oral health and anticipatory guidance.
Growth chart should be maintained for every child.

Concepts of Preventive Pediatrics:

The concepts of preventive pediatrics are broadly divided into --
1. Antenatal preventive pediatrics
2. Postnatal preventive pediatrics
3. Social preventive pediatrics
4. Community preventive pediatrics

➢ Antenatal Preventive Pediatrics:

It includes care of antenatal mother:
❖ Optimum nutrition
❖ Preparation for delivery and breastfeeding
❖ Prevention of communicable diseases
❖ Mother craft training
❖ Screening for structural anomalies and down syndrome:
1.Maternal serum alpha fetoprotein (MSAFP): AFP is an onco-fetal protein. It is produced by yolk sac and fetal
liver. Highest level in fetal serum and amniotic fluid is reached around 13 weeks thereafter it decreases.
• ELEVATED LEVELS IN: Open neural tube defects, Multiple pregnancy, Rh isoimmunization,
IUFD, Renal anomalies
• LOW LEVELS IN: Downs syndrome, Gestational trophoblastic disease.
2. Quadruple (Quad) Screening: In recent years 3 others markers, MSAFP, unconjugated oestradiol (uE3),
inhibin A have been added to HCG to screen the chromosomal abnormalities. Quad screen can detect Trisomy
21 in 85% of causes with the false positive rate of 0.9%. Levels of serum analytes in cases with Trisomy 21,
HCG increased, uE3 decreased, Inhibin A increased and MSAFP decreased.
3. Prenatal Genetic Screening: Detection and identification of couples who are at risk for having child with an
inherited disorder. Prenatal genetic screening has evolved from age-old invasive techniques like CVS to non-
invasive techniques or cell-free fetal DNA like blood samplings. Another recent development in non-invasive
testing is the fetal cell-based approach.
a) CELL-FREE FETAL DNA: The current approach of using cell-free fetal DNA provides easier,
less labor intensive and less time-consuming ways. It comes with some drawbacks as maternal
obesity negatively impacts the diagnostic capabilities.
b) FETAL CELL-BASED APPROACH: This was developed to overcome the drawbacks of cell-
free fetal DNA. Trophoblasts are preferred over nucleated fetal red blood cells as red blood cells are
present in low concentrations & have markers with low specificity.
Trisomy 18,13,21 is associated with increased maternal age, increased fetal nuchal
transparency and decreased maternal serum PAPP-A. In down syndrome serum free beta HCG is
increased whereas in Edwards & Patau’s syndrome beta HCG is decreased.

❖ Gestational diabetes screening:

There are two ways of screening: UNIVERSAL SCREENING and SELECTIVE SCREENING
• In Universal screening all women are screened, while in selective screening only those women who have the
risk factors are screened. They are:
- History
- Clinical examination
- Age > 30
- Obesity
- Previous GDM
- Polyhydramnios
- Family H/O diabetes
- Repeated Infections
- Previous macrocosmic baby
- Macrosomia
- Bad obstetric history
- Glycosuria
- Polycystic ovary syndrome
• In selective screening there are some tests:
- A diagnostic100-g OGTT for those meeting the threshold value in the GCT.
- Fasting plasma glucose (FPG)
- 1-hour post-challenge glucose
- SESHIAH TEST

➢ Postnatal Preventive Pediatrics:

It comprises of following strategies:
❖ Promotion of exclusive breastfeeding
❖ Immunizations
❖ Introduction of complementary feeding in appropriate age
❖ Growth Monitoring and Promotion (GMP):
Weighing the child regularly and plotting the weight on the health card is an important tool monitor
the growth of the baby.
 Infants and young children should be weighed every month in the presence of their mothers and the
growth status of the child should be explained to the mother.
The growth chart kept in a plastic jacket could be entrusted to the mother. If the child is having
malnutrition, the mothers should be advised to provide additional food to the child every day.
Malnourished children should be followed up at home and mothers encouraged to come and ask
questions regarding the feeding and care of the child.

❖ Preterm or Low Birth Weight Infants:

- Breast milk is particularly important for preterm infants and babies with low birth weight (newborn with
less than 2.5 kg weight) as they are at increased risk of infection, long-term ill health and death.
- Keep preterm or low birth weight baby warm. Practice kangaroo care. Kangaroo care is a care given to a
preterm baby in which baby is kept between the mother's breast for skin-to-skin contact as long as possible
as it simulates intrauterine environment and growth.
- This helps the baby in two ways: 1. The child gets the warmth of the mother's body, and 2. The baby can
suck the milk from the mother's breasts as and when required.
- Such babies may need to suck more often for shorter duration. If the baby is not able to suck, expressed
breast milk may be fed with katori or tube. The unique composition of preterm milk with its high
concentration of protective substances makes it particularly suited for preterm babies. Preterm baby should
be fed every 2 hourly during the day and night.

❖ Prevention of accidents:
Accident is an unexpected, unplanned occurrence of an event Der which may involve injury.
As children grows and passes through various phases of development and learn new skills every day, they
become prone to have accidental injuries. Accidental injuries are one of the causes of morbidity and mortality
in children from infants to adolescents.
Major causes of accidents in children:
-Lack of supervision
-Inadequate infrastructure
-Excessive curiosity of child to explore the new things.
-Newly developed motor skills. Attention seeking behavior.
-Anxiety and stress.
Types of Accidents Occurring in Children
-Aspiration
-Suffocation
- Fall
-Poisoning
-Burns
-Motor vehicle accidents
-Bodily damage
Common Accidental Injury in Different Age Groups:
Infant: Falls, burns, cuts and injury, suffocation, foreign body (aspiration, ingestion, in the ear, nose, etc.)
Toddlers and preschoolers: Falls, burns, cuts and injuries, ingestion and aspiration foreign bodies, drowning
and near drowning, poisoning, electrocution, suffocation and strangulation, bites and stings, vehicle or
road-traffic accidents, sports injury, etc.
School-age children and adolescents: Sports injury, falls, electrical or instrumental injury, road-traffic
accidents, bites and stings, drowning, etc.
Safety precautions: The safety precautions according to various age groups are as follows:
For infants:
-Never leave an infant alone on cot or table or in unprotected place to prevent fall.
-Never give very small things to the child.
-Toys should not have removable small parts which can be aspirated or put into the ear or nose.
-Never feed solids which are difficult to chew, e.g. ground nut.
-Coins, buttons, beads, marbles must not be left within child's reach.
-Keep the stove or fire source and hot things far away from the child.
-Electrical appliances should be kept out of reach.
-Never leave the infant near water tub or pond and never allow to go out alone.
Toddlers and preschoolers:
-Never use negative statement for any activities, i.e., 'don't do that, 'don't go there, etc.
- Give proper directions for activity.
- Provide constant supervision.
- Protect stairs by gate and keep doors closed.
- Keep harmful substances like hot things, drugs, poisons, kerosine oil, electrical appliances, sharp objects,
etc. out of child's reach.
- Give adequate instructions to the caretaker to look after the child and to follow the precautions.
- Provide safe play materials and toys.
- Floor should not be slippery.
- Furniture should be placed firmly to prevent fall and the child should not be allowed to climb over it.
-The child must not be allowed to wear inflammable synthetic materials which may catch fire easily.
- Mother should not hold the baby in lap when drinking tea or coffee or during cooking.
- Children should not be allowed to play with cord, plastic bags or pillow which may cause suffocation.
- Batteries of the torch must not be left free to avoid risk lead poisoning.
- Children must not be allowed to stand in a car when motion.
- Electric switch should be out of child's reach.
For school children and adolescents:
- Teach safety precautions with fire, fireworks, match box electricity, sharp instruments, etc.
- The child should be taught swimming as soon as he / she is old enough.
- Encourage playing in safe places and supervise game whenever needed to prevent sports injury
- Discourage the children from kite flying from rooftops and playing door banging games and from closing the
doors with a lot of force.
- Children must not be allowed to play on streets, they should be taught about road safety, use of zebra crossing
and cautions in bicycles or tricycles riding.
-Never left the child alone in the car unless it has been ensured that the keys are not 'in'.

❖ Value of Play and selection of play material:

Play is universal for all children. It is work for them and ways their living. It is pleasurable and enjoyable
aspect of child’s life and essential to promote growth and development.
Importance of Play:
Physical development enhanced during play. Muscular and sensory abilities developed at the time of running,
climbing, riding cycle and in other active play.
Intellectual and educational development promote during play. Children learn color, size, shape, number,
distance, height, speed, name of the objects, etc. while playing with various toys and play things. Creative
 activity, problem solving, abstract thinking, imagination, communication and speech development occur
during play.
Speech development occur during play. Children improve their attention span and concentration by playing.
Emotional development: Play improves emotional development. Children express their fear, anxiety, anger,
joy, etc. during play.
Moral development: Play is the means of moral development. Children learn morality from parents, teachers
and other adults.
Types of Play:
Infants usually engage in social affective play, sense-pleasure play and skill play. In social affective play infants’
response by smiling, cooing to the interacting adult.
Preschool children enjoy dramatic play through which they identify themself with adult and dramatize adult's
behavior. Structured formal play begins to be played during later preschool years.
School children enjoy competitive sports, games and they develop hobbies for recreation and diversion. School
age children imitate and dramatize more complex activities even acting out stories in books.
Adolescents and older children engage in a more sophisticated type of fantasy activity called day dreaming. They
spent their leisure time in competitive sports, operating computers, watching TV.
According to Parten and Newhall (1943), play behaving can be described as-unoccupied, solitary,
onlooking, parallel, associative and cooperative.
In unoccupied play behavior, the child is not involved in play activity but may move around randomly.
Solitary independent play indicates when the child plays alone independently. Toddlers and pretoddlers engage in
this type of concentrating play with less interaction with others.
Onlooker play behavior found when the child watches others play but does not become engaged in their play.
Parallel play is an independent play activity when the child plays alongside other children but not with them. They
play similar or identical play as other children play nearby. Toddlers typically play in this manner.
In associative play social interactions occur children. This is common in preschool age group.
Cooperative play behavior is found in preschool and engage in formal game in football or dramatic play of life
situation.
Selection and Care of Play Materials:
- Safe, washable, light weight, simple, durable, easy to handle and non-breakable.
- Realistic, attractive, constructive and offer problem- solving opportunities.
- No sharp edges and no small removable parts which may be swallowed or inhaled.
- Not over stimulating and frustrating.
- No toxic paints, not costly, not inflammable and not excessive noisy.
- Play things with electrical plugs should be avoided, only children over 8 years of age should be
permitted to use them.
Suitable Play Material According to Age:
Infant: Infant learns motor skill, bodily control and co- ordination by various means. The play materials
suitable for them can be as follows: hanging cradle toys, musical toys, balloons, rattles, etc.
4 to 6 months: Soft squeeze toys, rattles, toy animal, balloons, etc.
7 to 9 months: Squeeze and sound toys, blocks, cubes, plastic, ring, rattles, etc.
10 to 12 months: Motion toys, water play, blocks, doll, ball, musical toys, picture books or stiff cards, rocking
horse walker, transporting objects, pull and push toys.
 Toddlers: They should be provided with fitting toys, pull- push toys, pyramid toys, blocks, vehicles, ball, doll,
pots and pans, household articles, mud or clay, crayons, picture books or cards, play telephone, doll's house,
etc.
Preschool children: Suitable playthings for this group are puppets, animals, dolls, doll's house, carpentry
tools, large blocks, paint materials, colored picture books, doctor set toys, hospital equipment (like plastic
syringe, blunt scissors housekeeping toys, paper-modeling clay, cooking material tricycles, etc.
School-age children: Toys are popular up to 8 years age. Children of this group enjoy games of muscular
activity, running, climbing, swinging, etc.

➢ Social preventive pediatrics:

It is defined as the application of principles of social medicine to pediatrics to obtain a more complete
understanding of the problems of children in order to prevent and treat disease and promote
adequate growth and development through an organized health structure.
It includes -
❖ Collection and interpretation of community information to identify at risk
children.
❖ Correlation of vital statistics characteristics. with social and biological
characteristics.
❖ Implementation of child welfare policies and schemes.
❖ Promoting healthy environment by maintaining rights of children.
❖ Identification and rehabilitation of mentally and socially challenged children.
❖ Concerned with the delivery of comprehensive and e continuing child health needs (total
health needs):
❖ Healthy and happy parents
❖ Balanced and nutritious diet
❖ Clean, healthful house and environments.
❖ Developmental needs like play, amusement, love, affection, security, recognition,
recreation, company with other children
❖ Educational provision/opportunities.

➢ Community Preventive Pediatrics:

A concept rather than a branch of pediatrics, implying that “health is determined by interaction
between the child, his environment and the society in which he/she lives.” The objective is to
carry the health care to the doorstep of the needy.
The two essential areas of study in community pediatrics are:
❖ The health of the child population in relation to its social environment, i.e., the total
community.
❖ The health of the individual child as a result of multitude social influences (both
positive and negative).
❖ Health care goes to the susceptible population, thus ensuring protection to those who may
not otherwise seek advice.
❖ The concept ensures community participation at all stages.
 ❖ A community project can be started in a simple mud-walled/tiled structure. The equipment
and manpower, locally available at relatively cheap.
❖ Monitors the health and nutritional status of infants and children on a continuous basis;
this brings down the mortality and morbidity considerably.
❖ Contributes to family welfare by ensuring survival of the child and convincing the parents
of the advisability, to “restrict the number of children to 1-2”.
❖ Millenium Development Goal:
Reduces undue burden on the hospitals, which in any The MDGs originated from the
Millennium Declaration adopted by the General Assembly of the United Nations in September
2000. Representative from 189 countries met at the Millennium Summit in New York, to adopt
MDG.
Governments set a date of 2015 by which the countries would meet the following MDGs:
Goal 1: Eradicate extreme poverty and hunger.
Goal 2: Achieve universal primary education.
Goal 3: Promote gender equality and empower women.
Goal 4: Reduce child mortality rate.
Goal 5: Improve maternal health.
Goal 6: Combat HIV/AIDS, Malaria and other diseases.
Goal 7. Ensure environmental sustainability.
Goal 8: Develop a global partnership for development case, are not the right place for tackling
most of the problems encountered in the developing regions.
India Government also fixed the targets for achieving the MDGs, 18 targets are
present. Here I will discuss about Goal 4 and Goal 5 which is related to child health.
Goal 4: Reduce Child Mortality:
Target 5 is to reduce under-5 mortality rate by two thirds, between 1990 and
2015, and indicators are:
• Under-5 mortality rate
• Infant mortality rate
• Percentage of 1-year-old children immunized against measles.
Policies And Programs:
• Reproductive and child health (RCH)
• Focus during the tenth plan
• National Polio Surveillance Program (NPSP)
• The Oral Rehydration Therapy (ORT) Program
• Acute Respiratory Infections (ARI) Control
• Tenth Five Year Plan
• Twelfth five-year plan (2012-2017)

Goal 5: Improve Maternal Health:

Target 6 is to reduce the maternal mortality ratio by threequarters, between 1990
and 2015 and indicators are:
• Maternal mortality ratio
• Percentage of births attended by skilled health personnel.
 ❖ Sustainable Development Goal: Goal 3.2: By 2030, end preventable deaths of newborn
and children under 5 years of age, with all countries aiming to reduce neonatal mortality to
at least as low as 25 per 1000 live births.
Some of the SDGs are:
• Goal 1: No poverty
• Goal 2: Zero hunger
• Goal 3: Good health and well-being
• Goal 4: Quality education
• Goal 5: Gender equality
• Goal 6: Clean water and sanitation
• Goal 7: Affordable and clean energy
• Goal 8: Decent work and economic growth
• Goal 10: Reduced inequality
• Goal 13: Climate action
• Goal 14: Oceans
• Goal 15: Biodiversity, forests, desertification
• Goal 16: Peace and justice strong institutions

Scope of Preventive Pediatrics:

1. Pediatrics is medicine at a special age period and pediatrics is all medicine and not a branch.
Nevertheless, the size of the problem affects about 38% of the population of the country and
its importance lies in laying the foundations of health in early childhood when
maximum growth and development in every direction is taking place.
2. There should be a strong case for starting medical students in the preclinical years to
understand health and disease in the child. The student is trained to make observations
in order to diagnose.
3. The link-up of pediatrics with several other disciplines brings several
underdisciplined into prominence, should as child-psychology and preventive and
social pediatrics. outpatient, the well-baby clinic, the maternal and child health
(MCH) and the social health clinics afford opportunity to the medical and nursing
student particularly in seeing total family care.
4. Communicable diseases and immunization programs are the best approaches in
preventive pediatrics and social medicine. These are most common in the early age
groups and have specific disease prevention.
5. Preventive and social pediatrics form the best all-around approach to preventive and social
medicine, during the clinical years.
6. Preventive and social pediatrics form the best all-around approach to preventive and social
medicine, during the clinical years.

Nurse's Responsibilities in Preventive Pediatrics:

The role of the pediatric nurse is constantly changing. These changes are as a result
of expanding medical and nursing practice, emerging challenges in different aspects of child care, consumer
demands & technological advancements.
The role of the pediatric nurse may vary from one institution to others, but basic responsibilities remain the same.
Roles of pediatric nurse are:
1. Primary care giver
2. Coordinator and collaborator
3. Advocate
4. Health educator
5. Consultant
6. Counselor
8. Recreationist
9. Social worker and
10. Researcher

1. Primary care giver: Pediatric nurse should provide preventive, promotive, curative and rehabilitative care in
all levels of health services. In hospital, care of sick children includes comfort, feeding, bathing, safety etc. At
community set up, basic responsibilities include health assessment, immunization, primary health
care & referral etc.
2. Coordinator & Collaborator: The nurse plays an extremely important role with the combination of health
care team members. Nurse maintains good inter personal communication with the child, family and health team
members.
The nurse coordinates nursing care with other services for meeting the needs of child. For ex: physician, social
worker, surgeon, physiotherapist, dietician etc.
3. Nurse Advocate: The pediatric nurse acts as an advocate to safeguard the child's right, to assist & to provide
best care from the health care team.
Nurse acts as a representative for the child, family & other health care providers. Ex: it can range from consulting
dietary department for special foods to arrange team meeting to discuss plan of care with other
health team members.
4. Health Educator: The nurse's goal of health teaching is to provide information to the child parents and
significant other about prevention of illness, promotion or health maintenance.
Characteristics of nurse teacher includes: 4 C's
C- Confidence
C- Competence
C- Communication
C- Caring & empathy
5. Nurse Consultant: The pediatric nurse can act as consultant to guide parents for maintenance and promotion
of health. For ex: Guiding parents about feeding practices, accident prevention
6. Nurse Counselor: Providing guidance to parents in health hazards of children and help them for own
decision making in different situations.
7. Case Manager: The pediatric nurse should organize care, monitor and evaluate patient treatment for
successful outcome. She/he acts as a manager of pediatric care units in hospital clinics and community.
8. Recreationist: The pediatric nurse plays supportive role for the child to provide play facilities for recreation
and diversion. It helps to decrease crisis imposed by illness or hospitalization
9. Social Worker: Pediatric nurse can participate in social services or refer child & family child welfare
agencies for necessary support.
10. Nurse researcher: Research is an integral part of professional nursing. Pediatric nurse should participate or
perform research activities. It helps to provide basis for changes in nursing practice, improvement in the child
health care and evaluate the care.
 ROLE OF PEDIATRIC NURSE:
The pediatric nurse's role is unique because of developmental immaturity and vulnerability of children. The
goals of nursing care of children, based on primary health care are:
1. Promote the healthy maturation as a physical, intellectual and emotional being within the context of his
family and communities (primary level).
2. Provide health care for the child who requires treatment from disease(s) (secondary level).
3. Dealing with the child's disabilities (tertiary level). Therefore, the role of the pediatric nurse includes:
I. In Primary Level:
Through health education to child and his parents and providing child's basic needs and immunization, she can:
1. Maintain child's health.
2. Help the child achieves his optima9 growth and development.
3. Prevent diseases and their complications.
II. In Secondary Level:
The nurse has to provide care to sick children and their families by:
I. Assessing their needs.
2. Planning for care.
3. Implementing the plan.
4. Evaluating children's condition.
5. Providing heath teaching to children and their parents
III. In Tertiary Level:
The nurse should assist children to return to their maximal level of functioning following illness
and/or disabilities.
As a nurse depends on:
- Education
- Experience
- Job structure
- Professional demand
- Preventive care
- Promotive care
- Curative care
- Health education
- Restoration health
- Co-ordination
The nursing responsibilities in preventive pediatrics can be summarized as follows:
 Creating awareness about the care of girl child and promotion of health of girls, the future mothers.
 Appropriate care of antenatal mothers to have healthy children and provision of mothercraft training.
  Adequate intranatal care to reduce perinatal hazards and neonatal problems.
 Promoting breastfeeding practices and providing essential care during neonatal period.
 Preventing vaccine-preventable diseases by improving immunization coverage following appropriate
techniques.
 Nutrition education about weaning, balanced diet, feeding practices, food hygiene, prevention of
malnutrition, etc.
 Health education and counseling on personal hygiene, hand washing practices, environmental sanitation,
 Promoting community hygiene by use of latrines, burning or burying household refuses, keeping the
sources and supply of water safe and clean.
 Prompt and adequate care of sick and injured child in comprehensive approach.
 Promoting self-care abilities of children and parents in preventive measures.
 Health supervision at regular interval for early interventions of childhood illnesses.
 Participating in the implementation of health programs and promoting the preventive activities for
improvement of child health.
 Promoting beneficial traditional child rearing practices for prevention of childhood illnesses.
 Involving family and improving community participation in pronation of child health and prevention of
childhood diseases.
 Participating and contributing in the planning of child health programs.

Conclusion:
Preventive care aims to avoid or delay the occurrence of diseases, to timely detect a disease, to
avoid or delay complications when the condition is already present, to avoid premature deaths
and to improve efficiency.
Prevention is cornerstone of primary health care. When it is provided
comprehensively, it increases the access and uptake of preventive services, which in turn
results in better health and improved quality of care. Nurses are the point of entry for pediatric
preventive services.
Their knowledge and skills enable them to provide effective public health
services to individuals, families and the community.
Bibliography:
1. Dutta Parul, Pediatric nursing, New Delhi; Jaypee brother’s medical publishers(P)
Ltd 3rd edition 2009, Page- 22-30

2. Dutta DC, Textbook of Obstetric, New Delhi; Jaypee brother’s medical publishers(P)
Ltd 10th edition 2023.
3. Pal Panchali, Textbook of pediatric nursing; CBS publishers and distributors (P)
Pvt Ltd. 2nd edition, 2021 page-123-130.
4. Park K, Preventive and social medicine; M/S Banarsidas Bhanot publishers (P) 24th
edition.