Voices from the field on

childhood pneumonia

Authors:
Shobha Shukla, Somya Arora, Shikha Srivastava, Rahul Kumar Dwivedi, Ritesh Arya, Neeraj Mainali,Nadeem Salmani,Jitendra Dwivedi,Jittima Jantanamalaka,Bobby Ramakant

These articles have been written as part of a series in lead up to the World Pneumonia Day, 12 November 2011. The views expressed in these articles are those of the Citizen News Service (CNS) writers and the persons interviewed by them. November 2011 CNS: This content is available under the Creative Commons Licence Attribution 3.0 Unported (CC BY 3.0) license

AUTHORS:
Shobha Shukla Somya Arora Shikha Srivastava Rahul Kumar Dwivedi Ritesh Arya Neeraj Mainali Nadeem Salmani Jitendra Dwivedi Jittima Jantanamalaka Bobby Ramakant

Publisher: Puja Prakashan, C-2211, C-block crossing, Indira Nagar, Lucknow-226016.

Price: Rs 50

The writers of Citizen News Service (CNS) come from affected communities who have something to say on issues they feel for, or are affected by, in their daily lives, and give a voice to the voiceless. CNS syndicates content generated in four languages (English, Hindi, Urdu and Thai) under Creative Commons (CC) attribution license and produces 4 hours of radio programmes daily for FM radio in northern Thailand. CNS is facilitated by a Thailand-based company - Jay Inspire Co Ltd (JICL) - Media and Communication Services. Where People Come First! CNS: www.citizen-news.org

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TABLE OF CONTENTS
Acknowledgements……………………………………………………………………………………………………………. 4 IRONY: Preventable pneumonia is biggest killer of children under 5………………………………. 5 Wake up call after years of neglect on childhood pneumonia…………………………………………. 7 Early recognition & management of childhood pneumonia……………………………………………… 10 Gift your child low pneumonia risk by quitting tobacco………………………………………………….. 12

Theme 1: Importance of exclusive breastfeeding during the 1st six months of life in protecting children from pneumonia and many other diseases
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No Cocktail Feeding Please – Breastfeed Is Best For The Baby…………………………… 16 Mother‘s Milk Is The Best Milk……………………………………………………………………………… 19 Breastfeeding: A Child‘s First Immunization………………………………………………………. 21 Breast milk increases immunity in children…..………………………………………………….. 24 Mother‘s milk effectively prevents childhood pneumonia……………………………….….26 Mother‘s milk protects the child against pneumonia…………………………………………. 28 Exclusive breastfeeding vital for first six months………………………………………………. 30

Theme 2: Importance of good nutrition and hygiene (including hand-washing) in preventing pneumonia and other diseases
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Feed your child well: Prevent pneumonia…………………………………………………………. 33 Fight pneumonia with good nutrition…………………………………………………………………. 36 Cleanliness is next to godliness in preventing childhood pneumonia………………… 39 Feed right to fight childhood pneumonia……………………………………………………………. 42 Nutrition and cleanliness vital to protect children from pneumonia…………………. 45 Prevent childhood pneumonia by good nutrition………………………………………………… 47 Nutrition and hygiene helps protect children from pneumonia…………………………. 49 Good nutrition protects children from pneumonia…………………………………………….. 51

Theme 3: Importance of indoor air pollution (cook stove, tobacco smoke) in preventing pneumonia and other diseases
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Smoke-free Indoors For Pneumonia Free Lungs…………………………………………………. 54 Environmental Burden Can Weigh Down Your Child's Health…………………………….. 57 Passive smoking and lack of hygiene breeds childhood pneumonia………………….. 60 Indoor air pollution and childhood pneumonia………………………………………………….. 63 Secondhand tobacco smoke increases risk for childhood pneumonia……………….. 65 Indoor Air Pollution increases the risk of Childhood Pneumonia……………………….. 67

Theme 4: Access to affordable vaccines in our communities to prevent childhood pneumonia
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Vaccine Shots Can Combat The Death Shot Of Pneumonia………………………………… 70 Life Saving Shots For Killer Pneumonia………………………………………………………………. 73 A Shot In Arm Prevents Children From Pneumonia……………………………………………. 76 Pneumonia vaccination not reaching children who need it most……………………… 79 Get your child vaccinated against pneumonia…………………………………………………… 81 Pneumonia vaccination: Beyond reach for most children…………………………………. 83 Lack of awareness about pneumonia vaccine……………………………………………………. 85 Treat Pneumonia With The Wonder Drugs…………………………………………………………. 88 Antibiotic Therapy: The Pneumonia Panacea……………………………………………………. 91 Treat childhood pneumonia before it gets too late…………………………………………… 93 Barriers to accessing treatment for childhood pneumonia………………………………… 95 Childhood pneumonia a public health challenge……………………………………………….. 97 Childhood pneumonia is curable…………………………………………………………………………. 99

Theme 5: Access to standard quality treatment to save lives from pneumonia
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SPEAK YOUR WORLD ATHARVA: Tell-tale of a pneumonia crusader…………………………………………………………………. 101 About the CNS writers……………………………………………………………………………………………………. 105

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ACKNOWLEDGEMENTS
This report was written by ten CNS writers from India and Thailand, and published in three languages (English, Hindi and Urdu). The project was managed by Abhinav Bharat Foundation and supported by the 2011 Small Grants for World Pneumonia Day Advocacy Programme. We are grateful to the International Vaccine Access Center (IVAC), John Hopkins Bloomberg School of Public Health, GAVI Alliance, Global Alliance for Clean Stoves, and Best Shot Foundation for their support. Very special thanks are in store for CNS editors and translators who invested their time and energy in helping us give this shape to these publications. Ms Shehla Ghanim, Ms Bimla Misra and Ms Maya Joshi need a special mention and we salute their diligence and commitment. We would like to thank all those who were interviewed as part of this project and who took the time to share their views. We will also like to thank the International Union Against Tuberculosis and Lung Disease (The Union) and Nelson Hospital for Paediatric and Neonatal Medicine, Aliganj, Lucknow, among others. Lastly, thanks to the wonderful CNS writers who produced high quality articles in a short period of time, for making sure the voices from the communities, those most affected by childhood pneumonia, are heard. Concept, cover-page, design, layout: Jittima Jantanamalaka, CNS Thailand Photo credits: Shikha Srivastava, Shobha Shukla, Somya Arora, Rahul Kumar Dwivedi, Nadeem Salmani, Ritesh Arya, Neeraj Mainali, Jitendra Dwivedi, Jittima Jantanamalaka, and Bobby Ramakant

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IRONY: Preventable pneumonia is biggest killer of children under 5
Pneumonia can be prevented. It can be treated using first-line cheap and easily available antibiotics. Despite being preventable and curable, it continues to be the lead cause of morbidity and mortality for children below the age of five years. ―Pneumonia is a serious disorder affecting children even in their very early stages of life. The tragedy is that it is preventable. So, the top priority is to prevent it and, if it develops, then to provide timely treatment,‖ said Professor (Dr) Gourdas Choudhuri, Head, Department of Gastroenterology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences (SGPGIMS), Lucknow. Prof Gourdas Choudhuri is a noted public health expert too. HEALTH AND TREATMENT LITERACY ―Pneumonia occurs due to overcrowding in small homes with poor ventilation. The problem is further aggravated if one or both of the parents smoke. Passive smoking makes children more prone to chest and pulmonary infections. The other important aspect in preventing pneumonia is about hygiene - cleanliness and hand washing will prevent the germs from spreading. So, a general sense of hygiene should be there at all times. The other issue is of pollution - the fumes and dust in the air which children breathe. These particles will aggravate the bacteria and the virus if they are around. There is a need of a lot of awareness in mothers about picking up pneumonia at an early stage. Chest infections in children are bound to happen. But if a child has high or persistent coughing, a doctor should be sought so that antibiotics can be given timely. Timely access to medical care is crucial. In the early stages of the disease oral antibiotics work. But once the child becomes very sick, much more intensive care is required like hospitalisation, stronger and more expensive injectible antibiotics among others. So, proper awareness of the disease is an important issue in increasing the survival rate of children‖ said Prof Choudhuri. The role of vaccines in preventing the disease cannot be overlooked. Some vaccines, like the Hib vaccine, are good and a must, which can be given routinely. The pneumococcal vaccine is another good vaccine. ―But the issue is whether the strains causing the disease, which are present in the community, are the same as those present in the vaccine, otherwise the vaccine will not work, and the money spent will not get the protection one is expecting‖ said Prof Choudhuri. Pneumococcus, one of the germs that cause pneumonia in children, has many strains. ―The vaccine, which is currently available, has strains that are found chiefly in the western world, and its profile does not match with the strains found in our country. So a routine immunization with one vaccine may not work‖ explained Prof Choudhuri.

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Pneumonia is a serious infection of the lungs and can be caused by several germs. A vaccine will work well against some of these but not all. So it is difficult to have a complete vaccine for full protection. There is co-infection and co morbidity in pneumonia. Children suffering from some respiratory problem like asthma/chronic bronchitis; children whose spleens have been removed; children with a depressed immune system; malnourished children; and children more prone to pneumococcal infections - are more vulnerable to pneumonia, said Prof Choudhuri. OBESE CHILDREN ARE ALSO MALNOURISHED Lifestyle disorders play a crucial role in upping the risk to pneumonia. Obese children are also malnourished and so have a compromised immune system. So it is important to ensure that children keep an ideal body weight and use the sports field and/or do plenty of exercise to keep their lungs healthy. One of the most preventable factors is passive smoking. It does not directly cause pneumonia, but makes the child more vulnerable to it. Smoking does nobody any good, and fathers especially need to be made aware to be more responsible towards their children‘s health, said Prof Choudhuri.

Shobha Shukla – CNS

Changing behaviour towards health and social justice is a challenge

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Wake up call after years of neglect on childhood pneumonia
Pneumonia is the world's leading killer of children under five, claiming one young life every 20 seconds. That's more than AIDS, malaria and measles combined. Pneumonia is one of global health‘s most solvable problems. We have safe, effective and affordable tools to help children. Children should have access to effective and affordable treatment using antibiotics, which typically cost less than one dollar per dose. Tragically, only an estimated 1 of every 5 children with pneumonia receives antibiotics. Effective ―case management‖ strategies can help to ensure that children receive the right treatment for pneumonia quickly, even in the poorest communities. ―Pneumonia project in Malawi was based on our TB model which was delivering standard case management to children most at risk. The ‗know how‘ is there but getting the ‗know how‘ to the children is the problem. We know that the standard case management works but in most countries the problem is the weak health systems. One of the International Union Against Tuberculosis and Lung Disease (The Union)‘s strengths is technical assistance in trying to build up and give capacity building to the health systems. And we showed this that if we do this for children with lung disease then we can have a huge impact. And it doesn‘t cost a fortune. Another challenge is to delivering oxygen for children with very severe pneumonia. So this needs to be addressed as well‖ said Dr Penny Enarson, Head, Child Lung Health Division, International Union Against Tuberculosis and Lung Disease (The Union). DRUG STOCK-OUTS ARE MAJOR STUMBLING BLOCKS Antibiotics used for treating pneumonia are still the first line antibiotics (and not the expensive ones) such as Benzopenicillin, gentamycin, amoxicillin among others. ―These are quite inexpensive, easily managed but again usually it is the problem of logistics. Very often the governments either don‘t get the supply or don‘t maintain the supply of these antibiotics. So it is a major stumbling block for any strategy that is based on the standard case management because it relies on uninterrupted supply of antibiotics. These antibiotics are not expensive and in India especially because India is manufacturing lot of these drugs. Countries in South and South East Asia and Africa import these drugs from India. So it is a matter of commitment and ministries of health being logistically capable of keeping a

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stock of drugs always at the district and health centre levels for they are not expensive‖ said Dr Penny Enarson. IRRATIONAL USE OF DRUGS IS ANOTHER CHALLENGE A problem when we can buy drugs over the counter is the over use or irrational use of drugs. ―We follow rational use of drugs in standard case management and lot of it is about educating the mother on rational use of drugs for example children with common cold don‘t need antibiotics when it is so much easier for the physician to give it and mother is happy indeed. Children with common cold need some extra food and care etc else this is where probably drug resistance can occur‖ said Dr Penny Enarson. To do a drug-resistance study is quite expensive that is why lot of countries don‘t know their drug-resistance history. But by actually doing the treatment we do get to know that it works. In lot of countries there is no resistance to first line antibiotics but recently there has been some shift away from benzopenicillin and gentamycin for very severe pneumonia. Usually for less severe pneumonia we were earlier using cotrimoxazole but nearly every other country is resistant to that. More countries are now switching to amoxicillin which is a little more expensive. These are based upon the recommendations of the WHO and lot of these studies were done in Pakistan, said Dr Penny Enarson. It has shown in many studies that if we exclusively breastfeed an infant for first six months then the child is less likely to get infections and also it helps the immune system which is extremely important. However in countries where there is no family planning it is likely that there are more than one infant mother needs to be nourishing. So it can be quite difficult. The other issue is that mothers who are living with HIV and the whole issue around should they continue breastfeeding. But with antiretrovirals this issue has been addressed and studies show that exclusive breastfeeding cuts down on infections in the infant, said Dr Penny Enarson. Most of the deaths of pneumonia occur in under one year of age so that is why there is a real push for mothers to exclusively breastfeed and reduce the risk of the child dying, said Dr Penny Enarson. Added she: ―It has been shown that the children who are exclusively breastfed don‘t die of pneumonia as often as the ones who aren‘t.‖ Malnutrition is a huge problem and more so in Asia than anywhere else. 50% deaths in children are precipitated by malnutrition. Simple handwashing can cut down a huge amount of early infections especially during mother and child interaction. Malnutrition has to be addressed in conjunction with other disease programmes such as diarrhoea, pneumonia, measles, malaria, etc they all are compounded by malnutrition, said Dr Penny Enarson. Indoor air pollution is known to increase the risk of pneumonia. Especially for mothers who have infants on their backs or are holding the child while 8|Voices from the field on childhood pneumonia

cooking and smoke from cook stoves can up the risk. Secondhand smoke is a risk for developing pneumonia. There are two new vaccines for pneumonia, the HiB vaccine and pneumococcal vaccine. But both of them are expensive and not many countries have added them to their vaccine regiment because of the cost perhaps. These are major vaccines that really help in reducing deaths from pneumonia. RARELY A CHILD COMES TO CLINIC WITH ONE ILLNESS ―I can speak from my experience in Malawi that rarely we will see a child with one illness. So if the child has pneumonia they may have diarrhoea, measles, malaria, malnutrition, or co-infection with HIV in areas or populations where HIV incidence is high. It is difficult to tell the child who presents with pneumonia and malaria. Very often one or the other is missed. Meningitis is also another co-morbidity. People need to be aware that children don‘t come with just one problem‖ said Dr Penny Enarson. Pneumonia is still the number one killer of children. It is dreadful that these children should not be dying because it is quite easy to diagnose and fairly cheap to treat. The governments and others working on health systems strengthening need to understand that if they really want to reach the Millennium Development Goal no. 4 then they have to address pneumonia in children or they will not reach it. We can win the fight against pneumonia. More than one million young lives can be saved annually with vaccines and antibiotics, reducing indoor air pollution and through breastfeeding for the first six months of life.

Bobby Ramakant – CNS

―I can speak from my experience in Malawi that rarely we will see a child with one illness. So if the child has pneumonia they may have diarrhoea, measles, malaria, malnutrition, or co-infection with HIV in areas or populations where HIV incidence is high. It is difficult to tell the child who presents with pneumonia and malaria. Very often one or the other is missed. Meningitis is also another co-morbidity. People need to be aware that children don‘t come with just one problem‖
Dr PENNY ENARSON, The Union

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Early recognition & management of childhood pneumonia
Pneumonia is the leading cause of death among children under 5 years of age worldwide. One child dies from pneumonia every 20 seconds. That‘s 4,300 young lives lost every day. ―Pneumonia is a common respiratory infection in children and an important cause of morbidity and mortality, even in new born infants. 98% of children who die of pneumonia live in developing countries‖ said Professor (Dr) PK Misra, luminary paediatrician, who is the former Principal of India‘s prestigious King George‘s Medical College (KGMC, now known as Chhatrapati Shahuji Maharaj Medical University) and also the former Head of the Paediatrics Department at KGMC.

―Early recognition and early management are very important. If pneumonia cannot be managed at any health centre then early referral to a better health centre can become life saving at times‖
Prof (DR) PK MISRA

Added Prof (Dr) PK Misra: ―Pneumonia is an infection of the lungs, filling them with fluid. It causes cough and fever and can make breathing difficult. Severe pneumonia can be deadly.‖ In developing countries, children under 5 years of age are at risk, especially in the poorest communities. Tobacco smoke and other indoor air pollution increase susceptibility to pneumonia. Some children and adults are at greater risk because they have other infections, such as HIV. Children who are poorly nourished can also have weakened immune systems, putting them at higher risk of contracting pneumonia. Prof (Dr) PK Misra further explains that globally, bacteria such as Hib and pneumococcus are estimated to cause more than 50% of pneumonia deaths in children under 5 years of age. Viruses and fungi can also cause pneumonia infections. In resource-poor settings, pneumonia can be diagnosed by the symptoms it causes, including cough, fever and difficulty or fast breathing. Chest X-rays and laboratory tests can also diagnose pneumonia, but these tools are often unavailable in developing countries, especially in remote rural communities, making it more difficult to diagnose and treat pneumonia.

Some pneumonia can often be prevented with vaccines against Hib and pneumococcus. Measles and pertussis (whooping cough) infections can result in pneumonia complications, so vaccinating against these childhood diseases can prevent some pneumonia cases, said Prof (Dr) PK Misra. Inexpensive antibiotics can effectively treat pneumonia at the community level.

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―Early recognition and early management are very important. If pneumonia cannot be managed at any health centre then early referral to a better health centre can become life saving at times. Pneumonia can be effectively managed depending upon the condition by providing home-based care to the highest level of medical care but all the cases don‘t need highest level of medical care. Early recognition of signs that child needs medical attention by family members or those who look after the child and getting the child attended without delay at an appropriate health centre as indicated are crucial. Aseptic and clean environment should be maintained to raise the child and those who are caring for the child should wash their hands properly, wash clothes properly, and keep the umbilicus clean and not put anything there which can infect the child through umbilicus‖ said Prof (Dr) PK Misra.

Shobha Shukla and Bobby Ramakant – CNS

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Gift your child low pneumonia risk by quitting tobacco
One of the major risk factors for childhood pneumonia is exposure of the child to tobacco smoke. Another risk factor is biomass smoke (smoke coming out of cook stoves). ―Indoor air pollution includes both – tobacco smoke and biomass smoke and both of them are related to lung diseases. However the tobacco smoke is related to a larger variety of lung diseases than the biomass smoke is. Certainly tobacco smoke is clearly associated with tuberculosis (TB), both latent TB infection and active TB disease, and of course with chronic lung diseases like COPD and lung cancer. Association of biomass smoke with tuberculosis is not that clear but it is clearer with childhood pneumonia and very clearly associated with Chronic obstructive pulmonary disease (COPD) and lung cancer in women‖ said Professor (Dr) Donald A Enarson, Director (Scientific Activities), the International Union Against Tuberculosis and Lung Disease (The Union). Agrees Professor (Dr) Rama Kant, the World Health Organization (WHO) Director-General‘s Awardee for tobacco control (2005) and national Presidentelect of Association of Surgeons of India: ―The problem of indoor tobacco smoke pollution is more pronounced in the case of children living in hutments and slums. They are more exposed to secondhand tobacco smoke which contains over 4000 chemicals, many of which are not only carcinogenic, but reduce the child‘s immunity. These children are already very likely to be malnourished, deprived of proper ventilation and sunlight. On top of this right from the time they are inside the mother‘s womb, they are at a very high risk of being exposed to the hazards of secondhand tobacco smoke, even when they have not seen the light of life, as smoking is more common in poor people.‖

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There is an already established link between smoking and poverty. ―So according to me one important and worthwhile intervention is that facilities for tobacco cessation should be made available to people who are ready to quit. People are by and large more aware about the health risks of tobacco consumption and smoking, thanks to efforts made by NGOs and government and other agencies. But they do not know where to go to quit tobacco use successfully. I can say this with confidence that facilities for tobacco cessation are very meagre in our country, and this is a sad part. Unless we have facilities that can help people quit, and unless they are available constantly, many of the effort to control tobacco will go waste. The WHO had started around 20 such clinics, but gradually they are closing down due to paucity of funds and government efforts are not of that level which can manage these clinics‖ said Prof (Dr) Rama Kant. Prof (Dr) Enarson is in agreement: ―Difficulty with tobacco smoke is persuading people not to smoke or to stop smoking and persuading people to change their behaviour is not so easy. One of the things we focussed on was trying to catch people‘s attention based upon some of the personal experiences that they had. With biomass smoke we have tried to catch people‘s attention by identifying champions in the community that has suffered some adverse effects themselves and they can champion the issue with their neighbours. We did this for biomass smoke but same is true for tobacco smoke. In most societies the most challenging problem people face is to have a child who is hospitalized for a serious illness.‖ ―So we focussed on requesting the families to bring in their children for serious pneumonia and trying to talk to them about tobacco smoking and biomass smoke exposure. And in this way trying to persuade them that this is an important issue, educate them and encourage them to be champions of health in their own communities. If someone from outside the community comes in and begins to preach to people that is not a very successful way to change their behaviour‖ added Prof (Dr)

―Indoor air pollution includes both – tobacco smoke and biomass smoke and both of them are related to lung diseases. However the tobacco smoke is related to a larger variety of lung diseases than the biomass smoke is. Certainly tobacco smoke is clearly associated with tuberculosis (TB), both latent TB infection and active TB disease, and of course with chronic lung diseases like COPD and lung cancer. Association of biomass smoke with tuberculosis is not that clear but it is clearer with childhood pneumonia and very clearly associated with Chronic obstructive pulmonary disease (COPD) and lung cancer in women‖ - Prof DONALD A ENARSON,
Director (Scientific Activities), International Union Against Tuberculosis and Lung Disease (The Union)

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Enarson. Suggests Prof (Dr) Rama Kant: ―So I want to emphasize two things - people need to be aware that smoking should be controlled and never done inside homes, and secondly cessation facilities will go a long way in preventing children from suffering from pneumonia and its complications from avoidable deaths. We have a jumbo system of public healthcare consisting of a large number of doctors, paramedics and other staff. But their services are not being utilised to the fullest, especially in the rural areas. So, cessation facilities can be integrated with the existing healthcare system, and piggy back on the existing health services.‖ Clearly pneumonia is the most important killer of small children in the world. ―Unfortunately we haven‘t paid that much attention to pneumonia as we have for other lung diseases and I feel that this should be a priority‖ said Prof (Dr) Enarson. Even among people living with HIV (PLHIV) pneumonia is probably more common than tuberculosis although tuberculosis co-infection is very important in PLHIV. We need to find a way to highlight the issue of pneumonia, said Prof (Dr) Enarson.

Shobha Shukla and Bobby Ramakant – CNS

We have a jumbo system of public healthcare consisting of a large number of doctors, paramedics and other staff. But their services are not being utilised to the fullest, especially in the rural areas. So, cessation facilities can be integrated with the existing healthcare system, and piggy back on the existing health services‖
- Prof (Dr) RAMA KANT - WHO Director-General‘s Awardee on tobacco control 2005

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THEME 1
Importance of exclusive breastfeeding during the 1st six months of life in protecting children from pneumonia and many other diseases

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No Cocktail Feeding Please – Breastfeed Is Best For The Baby
Mother‘s milk plays a key role in preventing childhood pneumonia, which is a very serious problem, globally killing one child (below 5 years of age) every 20 seconds. It is responsible for almost 1.6 million child deaths per year, which is nearly 20% of all paediatric deaths around the world. Most of these children (about 98%) who die of pneumonia are from the developing countries. In India, more than 40,000 children under 5 years of age succumb to pneumonia every year. Exclusive breastfeeding during the first six months of life is crucial in combating several diseases, including pneumonia, by supplying the infant with all the nutrients, as well as sufficient immunoglobulin antibodies, which provide immunity to the respiratory tract, and contribute significantly to the development of a healthy immune system. Infants who are not breastfed at all are 5 times more likely to die from pneumonia than those who are exclusively breastfed. One must not forget that pneumonia is an infection of the lungs, filling them with pus and fluid, limiting oxygen intake and making it hard to breathe. It occurs due to bacterial infections, (although viruses or fungi can also be the cause), which attack when the child‘s still-developing defence system is weakened by malnutrition, air pollution, co infections with HIV/AIDS, tuberculosis, influenza and measles, and low birth weight. However, currently only 38% children worldwide are exclusively breastfed. Barriers to exclusive breastfeeding include time constraints, cultural norms, multiple births, ready access to formula milk and lack of knowledge. Dr Dinesh Chandra Pandey, a Specialist in Paediatric Medicine at Nelson Hospital of Paediatrics and Neonatal Medicine, Lucknow, rues that, ―Nowadays we have what is called cocktail feeding which is more prevalent in mothers, especially in working mothers. So their children depend on top feed or fortified milk.‖ Dr Ajay Misra, Managing Director of the 36 bedded Nelson Hospital of Paediatrics and Neonatal Medicine, Lucknow, had treated 30 children with severe pneumonia during the past 6 months. When I visited his hospital in September 2011, five cases of neonatal pneumonia (less than 10 days old) were admitted in the hospital, along with a few older children.

Dr Dinesh Chandra Pandey

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Dr Amita Pandey, Associate Professor of Obstetrics and ―We come across early neonatal Gynaecology at the Chhatrapati pneumonias within 48 hours to 7 days Shahuji Maharaj Medical of birth. 50% of all deaths due to University (erstwhile King childhood pneumonia occur in George’s Medical College), neonatal cases. Studies have shown which is a leading government that 30% to 40% of still born babies, hospital of Lucknow, also confirms the high prevalence of and 50% to 60% of those who died early childhood pneumonia cases within 1 or 2 days, had evidence of she has to deal with. She says, pneumonia, as revealed by autopsy‖ ―We as gynaecologists, often - DR AMITA PANDEY, Department of come across early neonatal Obstetrics and Gynaecology, CSMMU pneumonias within 48 hours to 7 days of birth. 50% of all deaths due to childhood pneumonia occur in neonatal cases. Studies have shown that 30% to 40% of still born babies, and 50% to 60% of those who died within 1 or 2 days, had evidence of pneumonia, as revealed by autopsy.‖ Elaborating on the merits of breastfeeding, Dr Amita Pandey says, ―I work in a government hospital and the only feeding modality that is advocated and patronized in our setup is exclusive breastfeeding (no water, no sugar, no gripe water, no honey, no coconut water) during the first 6 months of life. We let the mother start feeding the baby as early as within 10 minutes of delivery. We put the baby, cord and all, on the mother‘s abdomen, and it crawls up and starts suckling. This early suckling also helps in the delivery of the placenta and the Dr Ajay Mishra with membrane.‖ Dr Ajay Misra feels that, ―Though mothers are aware of the benefits of exclusive breastfeeding, they are very conscious about their beauty and physical appearance and hence do not want to breastfeed. In villages, mothers prefer to feed the infants on cow milk, as they have many children.‖ According to Dr Amita Pandey, ―Poor mothers adhere more strictly to breastfeeding than those from the higher socio economic status. Girls from well off families generally have problems in initiating and maintaining breastfeeding. Many are working mothers who have to leave their baby 17 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a
Ms Shobha Shukla

home for long hours after a few weeks of delivery. So they either stop breastfeeding the child early and/or ensure that the child has at least one top feed. They feel that if the child is not initiated into top feed from the beginning, it will not accept it later and thus create problems for them.‖ A reason commonly cited by new mothers for not breastfeeding is that they are not able to produce any (or enough) milk in the first few days, forcing them to put the baby on top feed. But Dr Amita Pandey strongly contends that whatever colostrums the mother produces during the first few days, are enough nutrition for the baby. A full term baby has enough glycogen stored in her to help her sustain for the initial two days. Moreover, if the baby is put to breast, the mother is bound to lactate eventually. It is like a cyclic process—put the baby to breast, there is a cyclic release of hormones, and the mother‘s milk production increases. The more is the baby put to breast, the more would be the milk production. Ironically, Anuradha, mother of a one month old baby (delivered through a caesarean section in a private nursing home) told that as she did not lactate immediately after the delivery, the doctor allowed her to feed her baby on formula milk through an unsterilized cup and spoon for the first two days. Later she switched on to breastfeeding the child. Similarly, another young mother Beena said that she is breastfeeding her 12 days‘ old infant daughter, but has given her water too, with some medicine for diarrhoea. She was unaware of the harms of letting the baby drink water along with mother‘s milk. So there should be more awareness programmes at the community and hospital levels for young girls to understand the importance of exclusive breastfeeding. Doctors too need to inform them about the health benefits of breastfeed for the child. The World Health Organization recommends exclusive breastfeeding as the sole source of food until an infant is six months of age, and thence a combination of it with complementary foods till two years of age. Expectant mothers need to remember that their milk is one of the most important tools in the armoury of the baby to prevent pneumonia and several other diseases, and that contrary to popular myths, the baby needs mother‘s milk, and nothing but mother‘s milk during the first six months of life.

Shobha Shukla – CNS

The World Health Organization recommends exclusive breastfeeding as the sole source of food until an infant is six months of age, and thence a combination of it with complementary foods till two years of age.

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Mother’s Milk Is The Best Milk
Exclusive breastfeeding implies the concept of feeding the child only with mother's milk from the first hour of birth up to a minimum of six months, without any other supplement like water, honey or any top feed. During the initial post natal phase, breast milk is in the form of colostrums which has antibiotic like properties and lactoferins, which give the child an integral immunity against various diseases, including pneumonia. Breast milk is also rich in proteins, has enzymatic activity that prevents the growth of bacteria and viruses, and fulfils all the nutritional requirements of the new born for the first six months. Since, pneumonia is mostly caused by bacteria and viruses, so breast milk reduces their risk in many ways by affecting their viability. Moreover, breast milk also plays an important role in providing respiratory and gut immunity, thus preventing pneumonia in a big way. It helps to develop resistance in the respiratory tract (lungs) which is the main affected organ in pneumonia. Dr Jyotsna Mehta, senior Gynaecologist and Obstetrician, who runs a private nursing home extols the virtues of mother‘s milk, as well as the importance of breastfeeding the baby soon after birth. She says that, "We put the baby to the breast of the mother as soon as she is born. If it is a normal delivery then it is done in the labour room and if it is a Caesarean then after the operation we go ahead and let the mother breastfeed the baby even before shifting the mother out of the theatre." The children who are not at all breastfed essentially during first six months of life are five times more susceptible to pneumonia which is the single biggest killer of children under five, than those who are breastfed. Sub-optimal breastfeeding is a factor in 44% of all Acute Respiratory Infection deaths among infants. Globally, 62% of the children are not exclusively breastfed. There are innumerable myths about breastfeeding which need to be dispelled. Suckling of milk does not deform the shape of the breast. Rather, breastfeeding increases the involution of Uterus. It brings the mother back to her normal physical shape much faster, than if she does not breastfeed the child. According to Dr Vijaya Mohan, senior

Dr Jyotsna Mehta

The children who are not at all breastfed essentially during first six months of life are five times more susceptible to pneumonia which is the single biggest killer of children under five, than those who are breastfed. Sub-optimal breastfeeding is a factor in 44% of all Acute Respiratory Infection deaths among infants

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Paediatrician, Vivekanand Hospital, Lucknow, ―There are some instances of people who feel that mother's milk is not a sufficient diet for the baby and he should be fed with top feeds in order to provide complete nourishment. But this is a misconception. The doctors should counsel the mother to allay these fears.‖ According to Professor (Dr) YC Govil, Professor, Department of Paediatrics, Chhatrapati Shahuji Maharaj Medical University (erstwhile King George‘s Medical College), "Bottle feeds and formula milk, certainly cannot be a replacement for breast milk, because no human endeavour can put those factors which the Almighty has done. They may be sufficient in terms of nutritive value to some extent, but there are many other benefits Professor (Dr) YC Govil of mother‘s milk which the formula food cannot meet. Maternal and infant bonding cannot be provided by these foods. A lot of research has been done which has ultimately proved that Breast milk is the best milk.” Lack of education and awareness among the masses prevents many mothers from exclusively breastfeeding their baby. In some cases the mother herself is underfed which engenders milk production in her, while in other cases the mother is not aware of the benefits of breastfeed. Breastfeeding is fuelled by traditional norms, and the misplaced desire on part of the mother to feed the child well. And if the mother is a working woman, she may resort to top feeds for her convenience. Awareness and education about exclusive breastfeeding is the need of the hour. We should promote breastfeeding and good nutrition for women in both rural and urban areas. There should be provision of flexi hours for working mothers. They should be made aware of the utility of breast pumps. Breast milk is the child's natural immunity and he should not be deprived of it. So let all women promote it, as it has many pros and no cons.

Shikha Srivastava – CNS

―Bottle feeds and formula milk, certainly cannot be a replacement for breast milk, because no human endeavour can put those factors which the Almighty has done. They may be sufficient in terms of nutritive value to some extent, but there are many other benefits of mother‘s milk which the formula food cannot meet. Maternal and infant bonding cannot be provided by these foods. A lot of research has been done which has ultimately proved that Breast milk is the best milk‖
Professor (Dr) YC Govil, Department of Paediatrics, CSMMU

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BREASTFEEDING:
A Child’s First Immunization
Mother‘s milk is the ideal nutritionally perfect food for newborns and infants. It is like nectar for the infant and is aptly called the first vaccine that can be given to the child. Apart from the unique ability to nourish the baby, it is also packed with several antibodies (immune globulins) that provide protection against common childhood illnesses, including pneumonia, a prime cause of child mortality which kills more than 4,300 children everyday worldwide. It is safe, easy to digest, is readily available and very affordable. Breastfeeding is the cheapest and most effective way to ensure a child‘s health and survival. A lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year. Beyond the immediate benefits for children, breastfeeding contributes to a lifetime of physical and mental health and well being. It is no wonder then that the World Health Organization actively promotes exclusive breastfeeding for the first six months of the child‘s birth. According to Dr Neelam Singh, Consultant Obstetrician and Gynaecologist and Chief Functionary of Vatsalya Resource Centre on Health, ―Exclusive breastfeeding implies that the child should be only, and only, be on mother‘s milk for six months, and not given anything else like water, gripe water or honey. Breast milk contains a number of immune globulins which increase the child‘s resistance to a wide range of diseases especially pneumonia and diarrhoea. Apart from increased immunity, breastfed infants also have better mental development. There Dr Neelam Singh is evidence that the intelligence quotient (IQ) of these children is higher by 8 to 10 points as compared to children who are not breastfed. Breastfeeding also reduces the risk of allergic conditions like skin diseases, asthma and even coronary heart disease in later years of life.‖ Dr SN Rastogi, a renowned Pediatrician who runs a private clinic in Lucknow says, ―Exclusive breastfeed is the best feed that can be given to a child.‖ Dr SK Sehta, Consultant Pediatrician and Neonatologist, Lucknow, feels that breastfeeding builds an emotional bonding between the mother and the child which plays a crucial role in mother-child relationship. Also, breast milk has certain hormones (which are lacking in formula, cow/ buffalo milk)

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which increase the child‘s resistance to a host of diseases including pneumonia. Despite the medical fraternity vouching for the efficacy of mother‘s milk, less than 40% of infants below six months of age are exclusively breastfed. In fact only 15% to 20% of the mothers coming to Dr Neelam Singh were following this regimen strictly. Support for mothers is essential as many mothers may face initial hiccups to exclusive breastfeeding, like nipple pain; fear that there is not enough milk to sustain the baby; lack of information; and socio cultural barriers. According to Dr Neelam Singh, ―Not only the doctor, but everyone who converses with a new mother-- the nurse, attendant and her family members--has a distinct role to play. The doctor‘s responsibility is to assure the mother that she can give her child complete nutrition by exclusive breastfeeding and to ensure that breastfeeding is started early. The paramedical staff should educate her about the benefits of breastfeeding and help her continue with it. The family‘s role is to support her and take good care of her food and nourishment. For working mothers the workplace environment and working conditions should be baby friendly -- flexible working hours that allow mother to breastfeed her baby; separate feeding rooms where the infant can be brought at the time of feeding; and/ or maternity leave for six months. Many nations are working in this direction but in our country a lot needs to be done.‖ Dr SN Rastogi feels that, ―Some women are figure conscious and think that breastfeeding will spoil their figure. But this is a myth. In other cases mothers themselves are under fed and so they are not able to produce enough milk.‖ Dr SK Sehta, says, ―In India a large number of mothers are undernourished and there is the fear of insufficient lactation, so they switch over to top feed which is absolutely a wrong practice. If the child is being exclusively breastfed for the first six months, the chances of a large number of infectious diseases is drastically reduced. Only in extremely rare (around 1%) cases where we find that sufficient breast milk is not being produced, or if the mother is suffering from some serious ailment, that the doctor allows top feed Dr SK Sehta in the form of the infant formula milk available in the market, if the parents can afford it. But a number of drawbacks are associated with formula milk and bottle feeding. The level of hygiene demanded by bottle-feeding is very hard to meet here. This predisposes the child to infection. They also tend to dilute the milk which leads to undernourishment of the child.‖

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Dr Neelam Singh too agrees that, ―Infant formula milk may perhaps meet the nutrient requirements but it does not have immune globulins. Also, bottle feeding demands greater hygiene and cleanliness which is not possible in our country. India is a tropical country with high temperature that favours spread of communicable diseases, and formula milk cannot increase a child‘s resistance to fight diseases, whereas mother‘s milk has.‖ In the chaos of ignorance about the benefits of breastfeed, there are some sane voices of mothers like Mrs Alpana Singh, which are worth emulating. Alpana, a new mother who delivered her second child recently at a private nursing home (City Hospital) in Lucknow, says, ―I exclusively breastfed my first child during the first six months, starting from day one, after my caesarean delivery and did not give him even water or top feed. Since I had to join my workplace only after three months of maternity leave, I made use of the breast pump to store my breast milk for 3-4 hours. This way I tried my best to breastfeed my baby for at least one year.‖ Health facilities that support breastfeeding - by making trained breastfeeding counsellors available to new mothers - encourage higher rates of the practice. To provide this support and improve care for mothers and newborns, there are now more than 20 000 "babyfriendly" facilities in 152 countries, thanks to a WHOUNICEF initiative. Public health workers working with the masses have a distinct role to play in dispelling the misconceptions and socio-cultural dogmas associated with breastfeeding. We need to mobilize not only the mothers but also their families about the importance of exclusive breastfeeding. It needs a combined effort from the entire society so that breastfeeding is encouraged.

Somya Arora – CNS
(Published first in THE HINDUSTAN TIMES: 9 November 2011)

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Breast milk increases immunity in children
New-born children after birth should be given exclusive mother's milk for first six months because it increases their body's resistance and immunity for rest of their lives. "Breast milk not only protects a child from pneumonia but also many other infections. Breast milk increases body's immunity of a child. That is why risk of contracting pneumonia in exclusively breastfed children is less compared to those children who don't get exclusive breast milk during first six months of their lives. Apart from exclusive breastfeeding there are many other steps one can take to protect children from pneumonia such as protecting children from cold exposure" said a noted paediatrician from Gorakhpur Dr KN Dwivedi. Awareness about breastfeeding has increased over the past years. "Patients are more aware and conscious of breastfeeding their child. They are more likely to be aware about the benefits of mothers' milk for a new born child. The women who have newly become mothers and have just-delivered are eager to learn correct method of breastfeeding. Doctors are also promoting breastfeeding among their patients. There is no doubt that exclusive breastfeeding has gone up over the past years" said Dr KN Dwivedi. "Most of the mothers are breastfeeding their newly born children but there are still some who aren't doing so in the slum I live in. There are lot of programmes raising awareness about breastfeeding and its benefits for the newly born child due to which number of children being breastfed has gone up" said Pradeep Srivastava, a slum-resident from Gorakhpur.
Pradeep Srivastava

Another slum-resident Indravati shared her experience when her grandson contracted pneumonia. "My grandson got pneumonia and developed serious breathing problems, was out of breath, pain in abdomen and fever. Doctors said that due to exposure to cold weather the child has developed pneumonia. This grandson was breastfed for 5-6 months and then switched over to cow's milk" said Indravati. It should be noted that exclusive breastfeeding is taken as synonym to breastfeeding with children getting fed honey, water, and other feeds due to a range of reasons including cultural, traditional or others.

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Despite awareness about benefits of breast milk for the newly born child there are cases where mothers aren't able to breastfeed their child. The reasons might be different but the impact of children not getting breastfed is not desirable. "One of the biggest reason in my clinical experience for mothers not breastfeeding their child is lack of awareness. Still there are communities where awareness has to reach about benefits of breastfeeding. Most patients are able to understand the benefits of breastfeeding when it is explained to them. However there are traditional barriers too that at times prevent a child from getting breastfed. There are misconceptions too in our society that often refrain mothers from breastfeeding their children" said Dr Dwivedi. Using bottles to feed milk to children is also not advisable. "We should avoid feeding milk to children using bottles as first of all, it is very difficult to ensure that bottles are adequately cleaned and sanitised. This increases the risk of children contracting infections during bottle-feeding which is detrimental to their health and a very undesirable happening. Secondly the risk of aspiration pneumonia in bottle-fed children is four-to-five times more than breastfed children. This is because the milk can go to the wind-pipe of the children when bottle-fed putting the child in danger" said Dr Dwivedi. Children should be breastfed for the first six months of their life as it has a very positive, desirable and profound outcome on rest of their lives.
Dr KN Dwivedi

Jitendra Dwivedi – CNS
(Translation: CNS)

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Mother’s milk effectively prevents childhood pneumonia
Various doctors of Uttar Pradesh opine that mother‘s milk is very important during the first six months of a baby‘s life. It protects the child not only from pneumonia but also from various other infectious diseases like diarrhoea, malnutrition among others. It is also the most effective way to keep the child healthy. Infants should not be given any top feed, supplement or bottle milk during the first six months. According to a study, children who are not breastfed during the first six months have five times higher risk of mortality due to pneumonia than those who are exclusively breastfed during the first six months. The World Health Organization (WHO) has also recommended that exclusive breastfeeding is the sole source of a child‘s nutrition for the first six months. 44% infant mortality under one month of age is due to want of exclusive breastfeeding. According to Dr KK Verma, Senior Paediatrician, District Hospital, Bahraich, ―Mother’s milk has vitamins and colostrums (first milk) which plays a major role in protecting children from pneumonia and other infections and in keeping them healthy. Hence it is very important that every mother exclusively breastfeeds her child for the first six months. Children should not be given any top feed because the quality which mother‘s milk has is not present in any other thing.‖ Dr PK Mishra, Senior Gynaecologist, District Hospital, Bahraich, also opines, ―Mother‘s milk protects the child from various infections and disorders hence it is the best form of nourishment. Nothing else can be better than mother‘s milk. Hence we advise all to-be mothers who visit our hospital to exclusively breastfeed their child for the first six months and not give any other milk or bottle feed.‖ According to Dr Kumud Anup, Paediatrician, Lucknow, ―Mother‘s milk is the best milk. It not only prevents infectious diseases like diarrhoea and gastroenteritis (burning sensation in the stomach), but also helps in the physical development of the child. It also increases child‘s immunity and body‘s resistance for other diseases. Hence mother‘s milk is complete nutrition for the child during the first six months. There is no need to give any other food supplement to the child.‖
Dr KK Verma

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According to Dr KK Verma and Dr PK Mishra of Bahraich District Hospital, approximately 70% mothers who visit their hospital do breastfeed their child. Dr Mishra also asserts, ―Urban mothers are not able to breastfeed their children because of several reasons: Working mothers cannot breastfeed their child on time, others do not exclusively breastfeed their child or some do not want to. There is need to Dr PK Mishra educate and mobilise common masses in this regard. It has been seen that if the doctor appropriately advises the mothers, they do follow it and breastfeed their child.‖ Whereas on one hand the doctors of the Bahraich District hospital opine that most mothers breastfeed their children, on the other hand there are some beliefs prevalent in the society according to which a newborn child is given goat‘s milk, water or something else even before mother‘s milk. This is evident from the fact that a mother who brought her three day old child suffering from pneumonia to the Bahraich district Hospital says, ―We are feeding our child with goat‘s milk because it is our family‘s old tradition that newborn child is given goat‘s milk initially.‖ Another mother of two and a half year old child sufferer of pneumonia stated that she could not breastfeed her child because milk was not being produced at that time. This kind of practice that prevails in our society is a big obstacle to the proper development of children. In fact it is a curse. There is need to mobilise not only doctors but also mothers in this regard. It has often been noticed that when doctors advise their patients and explain them well about the importance of breastfeeding, mothers heed to their advice and breastfeed their children. There is lack of awareness in the society. We need to educate mothers and make them aware. This will ensure a wholesome change in the society.

Rahul Kumar Dwivedi – CNS
(Translation: Somya Arora – CNS)

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Mother’s milk protects the child against pneumonia
Right after birth children should be given mother‘s milk only for first six months of their lives because it protects them from infections such as pneumonia, diarrhoea, among others. ―Mother‘s milk has desirable and beneficial antibodies that help the child protect herself/ himself against pneumonia and other infections. That is why it is strongly recommended that mothers should exclusively breastfeed their child for the first six months‖ said Dr Abhishek Verma, Senior Paediatrician, Dr Ram Manohar Lohia Hospital in Gomti Nagar, Lucknow. ―We counsel and prepare the woman on exclusive breastfeeding when she registers herself for antenatal care. At the time of birth and during postnatal care too healthcare workers make an extra effort in stressing Dr Abhishek Verma benefits of breastfeeding. Most mothers are comfortable in breastfeeding their child however in some cases mothers aren‘t in a position to breastfeed and incidence of childhood pneumonia, diarrhoea, malnutrition and other associated health problems is higher in such children who aren‘t breastfed‖ said Dr Verma. ―We don‘t advise feeding children with bottles. When children require additional nutrition then we recommend home-made food only and mother‘s milk is the best food for the baby, especially for first six months. Milk other than mother‘s milk doesn‘t have enough nutritional value for human being‘s baby that is why we make all efforts to ensure that the mothers breastfeed their children‖ said Dr Verma. ―When the child is born then they don‘t have a strong immunity to fight diseases. That is why children are unable to defend themselves from infections. But if the child is breastfeeding then she or he gets enough antibodies that help fight the infections and build body‘s own defence mechanism (immunity) against such diseases. Children who get exclusive breastfeeding are likely to be protected from conditions such as pneumonia, tuberculosis, common cold, diarrhoea, among others. That is why we encourage the mothers to exclusively breastfeed their child for first six months at least‖ said Dr Rama Shankhdhar, senior Gynaecologist and Obstetrician, Rama Consultations and Training Centre, C-block crossing, Indira Nagar, Dr Rama Shankhdhar Lucknow.

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―In some cases despite medication mothers are unable to produce enough milk. We still recommend that they should breastfeed as far as possible and complement with additional nutrition as required so that the child doesn‘t remain hungry. When mothers are able to normally produce enough milk for the child, then there is no need to give anything other than her milk to the child. Mother‘s milk is the best nutrition a child can get for first six months. However when mother‘s milk is not enough then they can feed the child using bottles. When the child is of 3 months age then they can also give filtered lentil water‖ said Dr Shankhdhar. Dr RS Dubey, Chief Medical Superintendent (CMS) of Dr Ram Manohar Lohia Hospital in Gomti Nagar, Lucknow also supported that children after birth should be exclusive breastfed for first six months. ―When mothers try to feed the child using a spoon milk at times goes into the respiratory tract (instead of food pipe) of the child. Mothers should elevate the head of the child while breastfeeding because then the risk of milk going into the respiratory tract is low. Children should be breastfed for first 6-12 months. This will also prevent the child from infections. That is why mothers of children born in our hospital are counselled and encouraged to exclusively breastfeed their child for first six months‖ said Dr Dubey. A child who was born in Dr Ram Manohar Lohia Hospital to parents who live in Ismailganj slums (behind this hospital) provides a reality check. The mother (Rekha) of this pneumonia-stricken child (Tulsi) said that she was not counselled or given information about breastfeeding. However as per the tradition she did breastfeed the child. Despite breastfeeding her child developed pneumonia. From the same slums we also spoke to three more mothers with pneumonia infected children (Jyoti, Yasmeen and Fareed) who had breastfed their children but still their children developed pneumonia. Upon closer review, there are other risk factors in the slums that increase the risk of pneumonia for children such as exposure to second-hand tobacco smoke, smoke from cook stoves, malnutrition, among others. Mother‘s milk gets easily digested by the child. So breastfed children are less at risk of facing indigestion or diarrhoea as risk of infection is low too. A child till six months of age is not required to take any other food except mother‘s milk as it contains all required nutrition.

Nadeem Salmani – CNS
(Translation: CNS)

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Exclusive breastfeeding vital for first six months
With changing weather condition children are more prone than adults to get sick. This is because of their low immunity and as they grow their body‘s self defence mechanisms (immunity) develops too. Exclusive breastfeeding is a blessing for a child in her or his first six months of life which is not only a complete balanced diet for the child, but also prevents infections transmitted through unhygienic feeding habits and boosts up a child‘s immunity significantly. If a child is not breastfed during first six months of life then the risk of contracting infections such as pneumonia goes up alarmingly. More than 1.6 million children under the age of 5 years die due to pneumonia despite pneumonia being preventable and curable too. The child should be breastfed within the first hour after birth and exclusive breastfeeding is strongly recommended for the first six months, said Dr Ajay Kumar, senior Paediatrician, Hope Mother and Child Care Centre, Lucknow. Breastfeeding as recommended by the World Health Organization (WHO) is instrumental in not only gifting the child with stronger immunity but also reduces the risk of serious infections such as pneumonia. However there are mothers who aren‘t able to breastfeed despite awareness. They complain of insufficient milk production at times which is a misconception because it is normal to have less milk in the initial phases of breastfeeding as the breasts produce a sticky ‗colostrums‘. If mothers continue to breastfeed then milk production goes up rapidly and is in the best interests of the child, said Dr Kumar. Colostrums also increase immunity in a child, said Dr Nidhi Johri, senior Gynaecologist and Obstetrician, Hope Mother and Child Care Centre, Lucknow. Mother‘s milk is the safest, cleanest and complete diet for a newly born child up to six months, said Dr Johri. Mothers often refrain from exclusive breastfeeding because either they feel that milk production is insufficient, or it causes pain in their waists, or they have a very hectic work schedule and it is difficult to provide the child exclusive breastfeeding. It is very difficult and at times impractical to ensure that the milk other than mother‘s own milk is sanitized and clean for the child, said Dr Johri. This is why some children who aren‘t breastfed develop pneumonia.

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Dr Ritu Garg, senior Gynaecologist and Obstetrician, Yash Hospital, Lucknow, also recommends exclusive breastfeeding to the mothers of newly born children for first six months of a child‘s life. However at times mothers are unable to breastfeed and in such situations she follows the WHO recommendation of supplementary food so that the child gets adequate nutrition as far as possible. She cautions that it is important that the bottle, utensils such as spoon or bowl, which are used to feed such children who cannot be breastfed adequately, must be clean and sanitized. Dr Garg recommends lentil or rice water, vegetables and fruit juices after five months. There is no substitute to exclusive breastfeeding, said Dr Santosh Rai, senior paediatrician, Vatsalya Clinic, Lucknow. Breastfeeding helps the child develop antibodies and boosts up child‘s immunity significantly, and such positive health outcomes cannot be optimally received by any supplementary food. Also Dr Rai cautions that bottle-feeding a child also ups the risk of getting milk in her or his respiratory tract (instead of food pipe) which can cause a form of pneumonia. If we don’t provide exclusive breastfeeding to a child and use supplementary food for child’s nutritional needs then we are also opening up a gateway for infections, said Dr Rai. There is no substitute to exclusive breastfeeding for a child during first six months of life – this is a clear message that all experts I interviewed have endorsed.

Neeraj Mainali – CNS
(Translation: CNS)

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THEME 2
Importance of good nutrition and hygiene (including hand-washing) in preventing pneumonia and other diseases

Mother and child with Pneumonia, in Ismailgunj slums, behind Dr RML Hospital, Gomti Nagar, Lucknow

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Feed Your Child Well:

Prevent Pneumonia
Pneumonia is the leading global killer of children under five, responsible for almost 1.6 million deaths per year, which is about one-fifth of all paediatric deaths around the world. Like other acute respiratory infections, pneumonia targets the world‘s most vulnerable children—those who are poor and mal/undernourished. The burden of pneumonia in the developing world is nearly 10 times that of developed world. In low income countries, pneumonia kills 7320 out of 100,000 children below 5 years of age, as compared to just 34 in developed countries. In South Asia and Sub Saharan Like other acute respiratory Africa 21% of all deaths in children are infections, pneumonia due to pneumonia. According to the targets the world’s most Acute Respiratory Infections Atlas 2010, lack of food contributes to 44% of deaths vulnerable children — from pneumonia in children globally. The prevalence, of childhood pneumonia is very high in India, and claims the lives of nearly 43,000 children every year. Proper nutrition is crucial to supporting the body‘s natural defences, and in helping to reduce the effects of a disease once it is contracted. There is a general consensus amongst doctors that malnutrition makes children immune suppressed, thus making them an easy target for a host of diseases, including pneumonia. Although poverty does lead to under nutrition, sometimes lack of knowledge about cheap but nutritive food items also prevents parents from providing a proper diet to their child. This is particularly true of urban families where processed and fast foods are becoming an integral part of children‘s daily diet. It is not uncommon even for urban slum dwellers to opt for greasy, fatty foods instead of the simple and highly nutritive, dal-roti.

those who are poor and mal/ undernourished. The burden of pneumonia in the developing world is nearly 10 times that of developed world

Professor (Dr) Gourdas Choudhuri, Professor and Head Gastroenterology Department, Sanjay Gandhi Post-Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, agrees that malnourished children are more vulnerable to pneumonia. Dr Choudhuri is a strong advocate of healthy living in children and feels that, ―Lifestyle disorders play a crucial role in management of diseases like pneumonia. Obese children are also malnourished and so have a compromised immune system. So it is important to ensure that children keep an ideal body weight and use the sports field and/or do plenty of exercise to keep their lungs healthy, in order to avoid the onset of pneumonia and other respiratory diseases.‖

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Dr Dinesh Chandra Pandey, a Specialist in Paediatric Medicine at Nelson Hospital of Paediatrics and Neonatal Medicine, said that till some years back pneumonia was less prevalent in affluent homes as compared to poor families. But protein-energy malnutrition, overcrowding, indoor /outdoor pollution and life style changes are taking their toll in the upper strata of society as well, where incidences of pneumonia and diarrhoea are on the rise. He lamented the popularity of fast foods which are poor in qualitative nutrition and are making children not only malnourished, but immune compromised also. So, pneumonia is no longer confined to poor households alone, though in developing countries like India, the incidence is higher in low income families. In Dr Pandey‘s opinion, ―Good nutrition need not be expensive. In some villages, children are more likely to have access to good nutritive diet, like fresh fish from the river, and But protein-energy pure cow/buffalo milk, which urban children may not malnutrition, be able to get that easily. Rural kids also have better and cheaper access to green vegetables and fruits. overcrowding, Urban families may be spending a lot on food but indoor /outdoor compromising on its nutritive aspect. I would pollution and life emphasize that diet should be nutritionally balanced by way of quality and quantity and be appropriate to style changes are the child‘s needs. Commercially available products like taking their toll in fast and junk food, which are heavily advertised in the upper strata of print and electronic media, should be avoided. Simple homemade food is good for the children.‖ society as well,

where incidences of pneumonia and diarrhoea are on the rise

Dr Ajay Misra, Managing Director of Nelson Hospital of Paediatrics and Neonatal Medicine, also stresses upon educating the public on the role played by good diet in preventing pneumonia and other diseases. He feels that, ―Parents should know the caloric needs of their child and ensure a balanced diet, containing adequate amounts of protein, carbohydrate, iron, and calcium for their children. I would highly recommend fibrous foods like green vegetables, lentils, simple roti/chapatti which is relatively cheaper and very good for the health. Parents should not initiate their kids to fast foods like pizzas, burgers, pastries, and colas drinks which are very harmful and should be indulged in once in a while only. I would strongly recommend fruits and not juices, as the former have enough fibre along with minerals.‖ Inadequate nutrition—in utero, during infancy, and early childhood is closely linked to lifelong immune deficiencies and acute respiratory infections like pneumonia. Inadequate maternal nutrition is also a major risk factor for later childhood pneumonia, as it is linked to low birth weight. Suboptimal breastfeeding also increases the risk of malnutrition and vitamin deficiencies in the infant. According to Dr Amita Pandey, Associate Professor, Department of Obstetrics and Gynaecology at the Chhatrapati Shahuji Maharaj Medical 34 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

University (erstwhile King George‘s Medical College), ―Although pneumonia affects rich and poor children, studies have shown that it is more common in mal nourished children. The same infection which ends in a mere Upper Respiratory Tract Infection (URTI) in a well nourished child is very likely to cause severe debilitating pneumonia in a malnourished one. I would like to add here that well fed children from well off families can also be malnourished due to a variety of reasons—they are not breastfed, they are on top feed which does not have enough proteins, or the top feed is mixed with water with the misconception of making it more digestible. As the child grows older milk is often supplemented with food items which may not be nutritive—like colas, chocolates, fries, burgers, pizzas. All this adds to malnutrition. As the baby grows older, it has to be weaned off mother‘s milk and given a protein rich diet, including fruits, to boost the immune system.‖ Improvements in health care and nutrition are interventions that can significantly reduce the incidence of pneumonia. According to the Acute Respiratory Infections Atlas, 2010— broad and integrated commitment on the part of the international community to improving living standards worldwide is the true foundation of prevention. With a view to improving nutrition and increasing immunity against pneumonia and other diseases, the World Health Organization stresses upon exclusive breastfeeding till six months; breastfeeding and complementary foods until two years of age; and thereafter an access to nutritional supplements and a healthy diet. Rising food prices over the past few years have added to the woes of malnutrition. At the time of writing this article, food inflation in India was at an all time high of 9.13%. It is imperative to have commitments from governments to combat malnutrition at the community level. Meanwhile one must remember that expensive foods may not always be nutritive, and that overfed/obese as well as undernourished children are low on immunity and hence breeding grounds for many childhood diseases, including pneumonia.

Shobha Shukla – CNS

Inadequate nutrition – in utero, during infancy, and early childhood is closely linked to lifelong immune deficiencies and acute respiratory infections like pneumonia. Inadequate maternal nutrition is also a major risk factor for later childhood pneumonia, as it is linked to low birth weight. Suboptimal breastfeeding also increases the risk of malnutrition and vitamin deficiencies in the infant.

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Fight Pneumonia With Good Nutrition
Good Nutrition implies an adequate and well balanced diet combined with regular physical activity. It is the cornerstone of good health and the key to improving a child‘s natural defences, and hence one of the most effective measures in preventing pneumonia. Besides, it also helps to reduce the length of the illness if a child does become ill. Good health and hygiene are the two facets of nutrition which help in building early immunity of the child by boosting the immune system. Nutrition relies on 'which' food and 'how much' food is required by the child. According to the World Health Organization (WHO), the

"Bad Nutrition is one extreme for affluent families, where kids are fond of junk food, which overfill them with calories; and at the other extreme are families with poor socioeconomic status who are forced to dilute milk and other food, which deprives them of the nutrient values."

biggest intervention against pneumonia is good nutrition. Every infant and child has a right to good nutrition
as per the Convention of 'Rights of the Child'. Keeping in mind the importance of nutrition, the Health Assembly in May 2010 adopted a resolution on infant and young child nutrition, to expedite the implementation of the global strategy on infant and young child feeding. People with adequate nutrition are more productive and can create opportunities to gradually break the cycles of poverty and hunger. Hence nutrition is indispensable to a healthy life. According to Professor (Dr) YC Govil, Professor, Department of Paediatrics, Chhatrapati Shahuji Maharaj Medical University, ―Good nutrition for children below 5 years of age should be exclusive breastfeeding during the first six months, and then gradual weaning by starting complementary food like cereals, mashed papaya, banana etc. As the child grows, all types of household diets must be added with some butter and ghee also, so that dense calories can be provided." It is a very popular notion that good nutrition has to be expensive. Dr Vijaya Mohan (Consultant Pediatrician, Vivekananda Polyclinic and Institute of Medical Sciences) says, "Good nutrition can be derived from common household items like cereals, pulses which are highly rich in protein. The only thing one should know is how to prepare them well i.e. hygienically and more nutritiously.‖

One cannot define nutrition in variant degrees-- if it is not good it will certainly be bad. Bad nutrition is such that either it leads the child to become overweight or underweight. Dr Govil says that, "Bad Nutrition is one extreme for affluent families, where kids are fond of

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junk food, which overfill them with calories; and at the other extreme are families with poor socio-economic status who are forced to dilute milk and other food, which deprives them of the nutrient values." Both these conditions are equally harmful for a child. According to estimates, approximately 46% children under 5 suffer from malnourishment, inadequate hygiene and sanitation in most developing countries. This is primarily the reason that in tropical countries deaths due to pneumonia are particularly high. Lack of food and hygienic conditions contributes to 44% of deaths from pneumonia in children. A key indicator of chronic malnutrition is stunting. Globally, 30% (or 186 million) of children under five are estimated to be stunted and 18% (or 115 million) have low weight-for-height, mostly as a consequence of poor feeding and repeated infections and unhygienic environment. Stunting rates among children are highest in Africa and Asia. Wasting is a severe form of malnutrition - resulting from acute food shortages and compounded by illnesses. Rising food prices, food scarcity in areas of conflict, and natural disasters diminish household access to appropriate and adequate food. If a child is under nourished then susceptibility to infections is increased and the defence mechanism is impaired, inviting many diseases including pneumonia. Maternal under nutrition, common in many developing countries, leads to poor foetal development. About 13 million children are either born premature or with low birth weight. Low birth weight children have approximately three times higher risk of mortality and of being malnourished in future. So the nourishment of mothers should also be looked into. If we pay attention to the nutrition of women right from their adolescence this vicious cycle of malnutrition can be broken. A well nourished mother is likely to give birth to a healthy child, thus reducing the chances of pneumonia and other diseases in infants. Hygiene helps nutrition in preventing pneumonia. According to DrJyotsna Mehta, practicing Gynaecologist and Obstetrician, Sahani and City Hospital, "Simple hygiene practices, like hand washing, in the post delivery period can reduce the risk of infections." Two key measures recommended by WHO and UNICEF to improve child survival are hand-hygiene and respiratory etiquette. Transmission of 37 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

community-acquired Acute Respiratory Infections occurs most commonly through inhalation of respiratory droplets produced by talking, coughing, spitting and sneezing. Coughs and sneezes should be covered with a tissue, cloth or mask. Hand-hygiene prevents the spread of common communicable diseases during coughing or sneezing. Proper sanitation, especially in developing countries where houses are overcrowded and not well ventilated, also helps in killing the disease germs. Hence following these simple remedies of hygiene will certainly decrease the risk of childhood pneumonia.

Shikha Srivastava – CNS

Mother and child with pneumonia (on the wooden bed) in a Gorakhpur slum

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Cleanliness Is Next To Godliness In Preventing Childhood Pneumonia
The best way to prevent serious respiratory infections such as pneumonia is to practice good hygiene. Infection control is highly dependent on the principles of personal hygiene, and by keeping ourselves and our surroundings clean, illnesses like pneumonia can be contained or even prevented. Most cases of pneumonia, whether acquired in the community or in the hospital, are caused by bacteria, and some by viral or fungal infections. These pathogens travel as airborne particles, ready to cause infection once they are inhaled and able to attack the lungs, filling the lung sacs with pus and fluid, limiting oxygen intake and making it hard to breathe. To prevent the recurrences of acute pneumonia, maintenance of community hygiene is as important as personal hygiene. Children are more vulnerable to this respiratory infection, due to their still developing immune system, and hence need special attention. So it is imperative to maintain proper hygiene and cleanliness to prevent the infection from spreading. Going back to the basics of hand washing and maintaining general cleanliness can go a long way in controlling pneumonia and several other childhood maladies. Studies have revealed that hand washing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally—acute lower respiratory infections like pneumonia and diarrhoea. In fact, studies have proved that children younger than 5 years in households that received plain soap and hand washing promotion show a 50% lower incidence of pneumonia. A simple way to help prevent Respiratory Syncytial Virus (RSV) associated pneumonia in children is to wash our hands often, especially before touching the baby. It would be worthwhile to mention here that according to the ARI Atlas, RSV infection is the most common source of severe respiratory illness in children worldwide killing an estimated 66000 to 199,000 children annually, most of who are in the developing world. According to Dr Dinesh Chandra Pandey, a Specialist in Paediatric Medicine at Nelson Hospital of Paediatrics and Neonatal Medicine Lucknow , ―Basic hygiene rules should be followed. Hand washing is very important. Food should be cooked with clean hands, kept in clean pots, served in clean plates and eaten in a clean place. It is important to keep the environment clean too. Unhygienic conditions

Studies have revealed that hand washing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally — acute lower respiratory infections like pneumonia and diarrhoea. In fact, studies have proved that children younger than 5 years in households that received plain soap and hand washing promotion show a 50%

lower incidence of pneumonia

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can result from over congestion, unplanned urbanization, improper ventilation in houses and a defective drainage system.‖

SIMPLE RULES OF HYGIENE are proper cleanliness, clean air, no overcrowding and protecting the child from other infected persons

Dr Amita Pandey, Associate Professor, Department of Obstetrics and Gynaecology, Chhatrapati Shahuji Maharaj Medical University (erstwhile King George‘s Medical College), also feels that it does not cost much to maintain proper hygiene. Simple rules of hygiene are proper cleanliness, clean air, no overcrowding and protecting the child from other infected persons.

Dr Ajay Misra, Managing Director, Nelson Hospital Of Paediatrics and Neonatal Medicine, lists the simple rules of hygiene as cleanliness and hand washing, and a clean, open environment. He insists that homes and hospitals, both should maintain high standards of cleanliness. The doors, windows, floors should be cleaned regularly and parents, family members, children, hospital staff should wear clean clothes. All this does not cost much—it only requires a proper mindset and attitude. Living in posh houses behind closed doors and windows, with no proper ventilation and flow of clean air also poses a danger. Babies are at particular risk of developing infections due to their delicate anatomy and levels of immunity. Bottle feeding, which seems to be a fashion in urban as well as rural India, seriously compromises the hygiene and health of the baby. Adherence to the regimen of exclusive breastfeeding during the first 6 months is low in India too, and mothers often combine breast milk with bottle feeding, increasing the risk of infection, and the risk that infants ingest water and other liquids that lack essential nutrients. In Dr Ajay Misra‘s opinion, ―These days, bottle feeding has become a fashion in urban as well as rural areas. This is more out of peer pressure and also because of personal convenience. Due to lack of proper information mothers feel that bottle feed will improve a child‘s health as they can feed the child more. Usually there is just one bottle and even that is not washed properly. This becomes a major cause of many infections. One should resort to bottle feed only if mother‘s feed is not possible due to medical reasons, and in that case very high standards of bottle hygiene should be maintained.‖ Dr Amita Pandey also advises against bottle feeding the baby for two main reasons: ―Firstly, maintaining proper hygiene with bottle feed is just not possible in a majority of cases. Secondly, a baby once acclimatised to bottle top feed, will not make the effort of taking mother‘s breastfeed easily because suckling the mother requires more effort than sucking the nipple of the bottle. ‖ She says that if the mother cannot breastfeed the baby all the while, then expressed mother‘s milk can be given as top feed with a sterilized cup and spoon. This milk can be stored in a sterile container for up to 8 hours at 40 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

room temperature and for 24 hours in the refrigerator. In fact mothers in western countries have been known to freeze their milk for as long as 3 months. In order to reduce the chances of spreading the infection of pneumonia, all of us should maintain good hygiene by frequently washing our hands after every contact with contaminated water/food, tainted surfaces, animals and animal waste, and by disposing the garbage in a proper manner to prevent germs from growing. The kitchen is another breeding ground for bacteria and strict kitchen hygiene is required at all times. A lot of cleanliness and a little bit of common sense is all that is needed to ward off illnesses like pneumonia.

Shobha Shukla – CNS

―Due to lack of proper information mothers feel that bottle feed will improve a child‘s health as they can feed the child more. Usually there is just one bottle and even that is not washed properly. This becomes a major cause of many infections. One should resort to bottle feed only if mother‘s feed is not possible due to medical reasons, and in that case very high standards of bottle hygiene should be maintained‖ - DR AJAY MISRA

―Firstly, maintaining proper hygiene with bottle feed is just not possible in a majority of cases. Secondly, a baby once acclimatised to bottle top feed, will not make the effort of taking mother‘s breastfeed easily because suckling the mother requires more effort than sucking the nipple of the bottle‖ – DR AMITA PANDEY

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Feed Right To Fight Childhood Pneumonia
Malnutrition or bad nourishment is a major health problem, especially in developing countries. Along with inadequate sanitation and poor hygiene, it plays a vital role in predisposing children to pneumonia and other diseases. Pneumonia is the leading killer of children under 5, claiming 1.5 million young lives every year. An estimated 98% of the children who die of pneumonia live in developing countries. We can reduce these deaths by twothirds, just by feeding our children with the right foods in right amounts and at the right time, in clean surroundings. Malnutrition takes into its purview undernourishment as related to poverty, and over nutrition that leads to obesity in children. Clinically, malnutrition is characterized by inadequate or excess intake of protein, energy, and micronutrients such as vitamins, and the ensuing An estimated frequent infections and disorders. Malnourished children, with a 98% of the weakened defence system, are prone to multiple infections children who which increases the chances of mortality and morbidity. Malnutrition, low birth weight, measles, Vitamin A deficiency, die of tuberculosis etc. increase susceptibility to pneumonia and pneumonia pneumonia makes a child more prone to other respiratory live in disorders like asthma.

developing countries. We can reduce these deaths by two-thirds, just by feeding our children with the right foods in right amounts and at the right time, in clean surroundings

Good nutrition is indispensable to building a child‘s immunity which not only reduces the chances of infection but also increases the ability to fight and recover from a disease. Dr Neelam Singh, Consultant Obstetrician and Gynaecologist, and Chief Functionary of Vatsalya Resource Centre on Health, asserts, ―Good nutrition in infants is highly important because it is that period of life when their nutritional requirements are very high due to very fast growth of brain and body. Hence we need to know ―which‖ foods and ―how much‖ of them are required by a developing child, as the nutritional requirements of different age groups of children are different. We must also remember that malnourished mothers often give birth to low birth weight babies. So, the nutrition of mothers should also be good, right from their adolescence, in order to bring healthy babies in the world.

Dr SK Sehta, Consultant Paediatrician and Neonatologist, Lucknow, says, ―These days, in big metropolitan cities, children are getting fast food, readymade meals, excessively oily and salty foods, all of which are making them more obese and increasing their risk of diabetes and cardiovascular heart diseases in future.‖

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Dr Neelam Singh also opines, ―Malnourishment is the reason for a high number of deaths due to pneumonia and diarrhoea in our country. In my state of Uttar Pradesh, approximately 46% children under 5 suffer from malnourishment. In one of our recent surveys we came across many new born infants who were being given tea and even cold-drinks. Babies are also given ―ghutti‖ (gripe water), and their top feed/formula milk is heavily diluted with water, either, to increase the quantity (and thus reduce expenses), or, due to the misconception that the child cannot digest pure milk. The child may not be given high energy food for similar reasons. Very often, food is prepared keeping in mind the likes of elders and not according to the requirements of a growing child.‖ Adding to the list of myths related to bad nutrition, Dr SN Rastogi, a leading private paediatrician of the city, comments that, ―There is a myth that the baby should not be given pure breast milk or cow milk, but it should be diluted with equal amounts of water, else it will cause diarrhoea. Under feeding in most children results from dilution of milk. Supplements which have high protein content should be given to low birth weight babies.‖ Dr Neelam Singh clarifies that, ―Good nutrition does not mean expensive food. Very often, expensive things lack sufficient nutrition or have the same nutrition as present in cheap, homemade food prepared from locally available resources. As an important example I would like to mention that although now the advertisement of Cerelac is not being broadcast on television, it remains a very popular food supplement. So much so, that even the household maids feed their children with it, in a bid to imitate their wealthy employers. Ceralac provides the same nutrition to the child as rawa/suji kheer (semolina), mashed daliya (porridge) and mashed dal (lentils) prepared at home. It is not only the illiterate masses of rural areas, but children of affluent and well-educated urban mothers also suffer from malnutrition.‖

―Malnourishment is the reason for a high number of deaths due to pneumonia and diarrhoea in our country. In my state of Uttar Pradesh, approximately 46% children under 5 suffer from malnourishment‖
DR NEELAM SINGH

Inadequate access to clean water and good sanitation also encourage the incidence of pneumonia. To emphasize the role of hygiene in controlling diseases we have a World Hand Washing Day. Dr SK Sehta says, ―Hygiene is very important for containing 43 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

the occurrence of any disease especially gastrointestinal Infections. Even in the case of pneumonia hand-washing before touching a child reduces transfer of infection to the child.‖ Dr Neelam Singh emphasizes, ―The carers of the child should be very cautious about hygiene and cleanliness. Hands should be washed properly with water and soap every time the child is cleaned after urinating/ passing stools, and also before and after feeding the child. The child should be given clean water to drink, and fresh and clean food to eat. The food should be kept covered and prevented from contamination. The child‘s surroundings should be kept clean and hygienic, water should not be allowed to collect, and the child should be bathed everyday and dressed with clean clothes. These simple hygiene practices play a crucial role in preventing infectious diseases, especially pneumonia and diarrhoea.‖ Dr SN Rastogi emphasizes on regular cleaning of the breasts before feeding the infant. His advice is that, if it is absolutely necessary to bottle feed the baby, a minimum of four bottles and 4-5 nipples should be used. They should be boiled properly before use. Babies should be made to wear clean clothes. Normally babies are dressed in old worn out clothes for first few months due to some tradition. This is not right.‖

The carers of the child should be very cautious about hygiene and cleanliness

Apart from international interventions, like reducing poverty, to cope with the problem of malnutrition, there is also a need to mobilize people about the importance of good nutrition. Dr Neelam Singh suggests, ―The different nutritional requirements of children of different age groups should be discussed with the common public. These discussions must be carried out not only in national and international conferences with professionals, but the message needs to be spread to the rural masses-- to the last family of the last village.‖

Somya Arora - CNS

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Nutrition and cleanliness vital to protect children from pneumonia
A balanced nutritious diet is a must for everyone especially for children as they are growing and their body‘s self-defence mechanism is developing. If the food we consume is not nutritious then instead of benefiting us it can cause serious harms. One of the possible outcomes of malnutrition is pneumonia more so when it comes to children. A balanced nutritious diet has a key role in developing a child‘s immunity, said Dr Santosh Rai, senior Paediatrician, Vatsalya Clinic, Lucknow. Vitamins, antioxidants, minerals and other essential nutritional components of a balanced diet define our immunity. Children who are malnourished are at an elevated risk of infections such as pneumonia, said Dr Rai. Dr Santosh Rai votes against eating junk food. We should maintain hygiene while preparing food for the child. It is not only stomach related ailments that are caused by lack of hygiene but also viral pneumonia can occur due to lack of cleanliness and hygiene. Every person who touches a child should first wash hands, and use clean utensils and clothes to attend to the child‘s needs, said Dr Rai. Exclusive breastfeeding is recommended for the children in first six months of their lives, said Dr Ajay Kumar, a senior Paediatrician, Hope Mother and Child Care Centre, Lucknow. After first six months of a child‘s life, gradually she or he should be given other nutritious food in addition to the mother‘s milk. Nutritious food need not necessarily be expensive. Dr Kumar advises against giving children fast-food or junk-food and stresses that mother‘s milk is the complete diet for the child in first six months of life and should not be supplemented with milk from cow or buffalo or powdered milk products. Milk of cow and buffalo is complete diet for their own baby calves and not for human child. We should not compromise on cleanliness and hygiene when it comes to children, said Dr Kumar. Dr Ritu Garg, senior Gynaecologist and Obstetrician, Yash Hospital, agreed too that nutritious diet need not be an expensive one. Dr Garg raises serious concerns on lack of hygiene maintained in child care and rearing. Mothers should wash their hands properly before feeding the child otherwise they

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are themselves putting their children at risk of contracting infections such as pneumonia, said Dr Garg. Not only a balanced nutritious food is important but also maintaining hygiene and cleanliness is a key, said Dr Nidhi Johri, senior Gynaecologist and Obstetrician, Hope Mother and Child Care Centre, Lucknow. Dr Johri was awarded the Gold Medal in her medical education. Often children become malnourished because of lack of awareness about a balanced diet in their parents and guardians. Dr Johri believes that neither the adults nor the children need expensive food. She recommends seasonal fruits and vegetables as they are good source of nutrition. At times patients pester her to prescribe protein drinks but she instead prioritizes seasonal fruits and vegetables. Most infectious diseases thrive due to lack of hygiene and cleanliness, said Dr Johri. She advises all mothers who come to her hospital to maintain high degree of hygiene and cleanliness in their routine child care and upbringing. Practices such as washing hands properly before touching the child or feeding the child, washing milk bottles, nipples, and other supplies which the child needs, are important to follow in hygienic manner. The child of Ashish and Sangeeta Nigam developed pneumonia five months after birth, so it is very important to observe high grade of cleanliness and hygiene to ward off infections.

Neeraj Mainali – CNS
(Translation: CNS)

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Prevent childhood pneumonia by

good nutrition
Good nutrition can save a child from malnutrition and pneumonia both. "Nutritious diet is the fuel of life, just what petrol is to a car. The best nutrition for a newly born child for at least first six months is mother's milk. Only after first six months, other food items are introduced very gradually and mother's milk is recommended for two years. By one year of age, a child can nearly eat whatever an adult person can eat too. Point to remember is that good nutrition is fundamental to a child's healthy tomorrow" said Dr KN Dwivedi, noted Paediatrician from Gorakhpur. Dr Dwivedi also discusses what are bad for the child in terms of nutrition. "Giving food supplements and other food or fluids right after the birth of the child (instead of mother's milk), not giving mother's milk, fast-food, food products that lack in nutritional values, unbalanced diet, not feeding on time, among others. A balanced nutritious diet is so important for the child. For a child up to six months of age, her/ his mother's milk is the best diet" said Dr KN Dwivedi. New-born children after birth should be given exclusive mother's milk for first six months because it increases their body's resistance and immunity for rest of their lives. Breast milk not only protects a child from pneumonia but also many other infections. Breast milk increases body's immunity of a child. That is why risk of contracting pneumonia in exclusively breastfed children is less compared to those children who don't get exclusive breast milk during first six months of their lives. Apart from exclusive breastfeeding there are many other steps one can take to protect children from pneumonia such as protecting children from It should be noted cold exposure. Awareness about breastfeeding has increased over the past years. "Most of the mothers are breastfeeding their newly born children but there are still some who aren't doing so in the slum I live in. There are lot of programmes raising awareness about breastfeeding and its benefits for the newly born child due to which number of children being breastfed has gone up" said Pradeep Srivastava, a slum-resident from Gorakhpur. Another slum-resident Indravati shared her experience when her grandson contracted pneumonia. "My grandson got pneumonia. This grandson was breastfed for 5-6 months and then

that exclusive breastfeeding is taken as synonym to breastfeeding with children getting fed honey, water, and other feeds due to a range of reasons including cultural, traditional or others.

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switched over to cow's milk" said Indravati. It should be noted that exclusive breastfeeding is taken as synonym to breastfeeding with children getting fed honey, water, and other feeds due to a range of reasons including cultural, traditional or others. Despite awareness about benefits of breast milk for the newly born child there are cases where mothers aren't able to breastfeed their child. The reasons might be different but the impact of children not getting breastfed is not desirable. "One of the biggest reason in my clinical experience for mothers not breastfeeding their child is lack of awareness. Still there are communities where awareness has to reach about benefits of breastfeeding. Most patients are able ―However there are traditional barriers to understand the benefits of too that at times prevent a child from breastfeeding when it getting breastfed. There are is explained to them. However there are misconceptions too in our society that traditional barriers often refrain mothers from too that at times prevent a child from breastfeeding their children‖ getting breastfed. There are - Dr KN DWIVEDI, Paediatrician, Gorakhpur misconceptions too in our society that often refrain mothers from breastfeeding their children" said Dr Dwivedi. Using bottles to feed milk to children is also not advisable. "We should avoid feeding milk to children using bottles as first of all, it is very difficult to ensure that bottles are adequately cleaned and sanitised. This increases the risk of children contracting infections during bottle-feeding which is detrimental to their health and a very undesirable happening. Secondly the risk of aspiration pneumonia in bottle-fed children is four-to-five times more than breastfed children. This is because the milk can go to the wind-pipe of the children when bottle-fed putting the child in danger" said Dr Dwivedi. Children should be breastfed for the first six months of their life as it has a very positive, desirable and profound outcome on rest of their lives.

Jitendra Dwivedi – CNS
(Translation: CNS)

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Nutrition and hygiene helps protect children from pneumonia
Nutrition, cleanliness and hygiene should be paid attention more so when a woman becomes pregnant. Good balanced nutrition for the pregnant woman and postnatal for her new born child is a blessing in warding off infections and boosting child‘s immunity. Childhood pneumonia is a common disease affecting an alarming number of children below 5 years of age. ―When a woman becomes pregnant then we advise her to take iron, calcium, protein rich diets or supplements such as soya-bean, or jaggery (rich in iron). Jaggery is a rich source of iron and is easily available in rural and urban India. Jaggery is also not expensive. Eating cottage cheese and drinking milk is recommended too as these are rich in protein and calcium both. If we take special care of pregnant woman‘s nutrition then the baby is more likely to be born healthy. Another benefit of providing good nutrition to the pregnant woman is that it is more likely for the delivery to be at full term (and not premature). If the child is born full-term and is not a premature born baby then the risk of infections is significantly reduced‖ said Dr Rama Shankhdhar, a senior Gynaecologist and Obstetrician, Rama Consultations and Training Centre, Cblock crossing, Indira Nagar, Lucknow. ―We should maintain high degree of cleanliness and hygiene. Before taking the child in our arms we should wash our hands properly. Before feeding the child, mother should wipe her breast with a wet and clean towel so that talcum powder or sweat or cream etc is wiped away and doesn‘t go in the child‘s mouth. The mother should take a daily bath, bathe her baby daily and change her or his clothes daily. Every time the child passes urine or stools please clean the child properly and keep her or him dry. Child‘s clothes should be washed properly. After six months too children should be fed homemade food only and refrain from giving spices or fast-food items to your child‖ said Dr Shankhdhar. ―We should provide a balanced nutrition to the mother and child (after six months). Our body needs proportionate amounts of carbohydrates, protein, and other vitamins and minerals and that is why it is important to ensure proper amounts of nutrition in our diet. If we provide a balanced nutritious diet to the pregnant woman and after delivery to the mother and child (exclusive breastfeeding for first six months) then the child develops strong immunity. A balanced nutrition will help the child fight diseases such as pneumonia‖ said Dr Abhishek Verma, Senior Paediatrician, Dr Ram Manohar Lohia Hospital in Gomti Nagar, Lucknow.

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Added Dr Shankhdhar: ―Every pregnant woman wishes for a healthy baby and prays that her child should remain away from all the diseases and infections. To fulfil her own desire she is required to ensure proper balanced nutritious diet especially when she becomes pregnant and also for her baby when she or he is born. She should ensure exclusive breastfeeding for first six months of her child‘s life. Her diet should include as appropriate nutritious food such as milk, eggs, fish or meat, green vegetables, food grains, lentil among others. Instead of sugar she should eat jaggery which is a rich source of iron. ‗Bajra‘ is a rich source of calcium.‖ If proper balanced nutrition is ensured for the pregnant woman and after birth for her child in early years, it helps build strong self-defence (immunity) in the child and reduces the risk of infections significantly.

Nadeem Salmani – CNS
(Translation: CNS)

―Every pregnant woman wishes for a healthy baby and prays that her child should remain away from all the diseases and infections. To fulfil her own desire she is required to ensure proper balanced nutritious diet especially when she becomes pregnant and also for her baby when she or he is born. She should ensure exclusive breastfeeding for first six months of her child‘s life. Her diet should include as appropriate nutritious food such as milk, eggs, fish or meat, green vegetables, food grains, lentil among others. Instead of sugar she should eat jaggery which is a rich source of iron. ‗Bajra‘ is a rich source of calcium‖
- Dr RAMA SHANKHDHAR, Gynaecologist and Obstetrician, RCTC, Lucknow

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Good nutrition protects children from pneumonia
Children, who are malnourished, undernourished or those who are not breastfed during the first six months of birth have less resistance towards diseases. As a result they are more prone to pneumonia. Thus good nutrition and mother‘s milk have an important contribution in preventing childhood pneumonia. Globally 44% infant mortality due to pneumonia is caused by malnutrition. According to the World Health Organization (WHO), pneumonia accounts for 1.9 million (1,900,000) under five child deaths per year globally. This is greater than deaths in children by other diseases. Pneumonia is a type of respiratory infection associated with fast breathing and affects the air spaces or alveoli of the lungs. In a healthy person after inhalation the alveoli get filled up with air, but in a pneumonia patient, these air spaces get filled up with pus and fluids which makes breathing difficult and excessively painful. This also limits the amount of oxygen that reaches the body. According to Dr KK Verma, Senior Paediatrician, District Hospital, Bahraich, ―Complete nutrition is very crucial in protecting children from pneumonia. This ensures that the body is getting adequate amounts of vitamins that prevent pneumonia. Children should be given pulses, chapattis and rice. Readymade baby food should be avoided as far as possible. This is bad nutrition for children.‖ Dr PK Mishra, Gynaecologist, District Hospital, Bahraich, also opines, ―Mother‘s milk is the best nutrition for children upto six months. After that porridge etc can be given. Bottle feeding should be avoided as it is not the right nutrition. There is lack of awareness among mothers. They need to be educated in this regard because if they are informed they will adopt these recommendations.‖ According to Dr Kumud Anup, Senior Paediatrician from Lucknow, suggests, ―Hand hygiene is very important which can prevent pneumonia and several other childhood diseases. Thus right nutrition not only protects children from pneumonia and other diseases but also aids in their physical development and building up of body resistance. Pulses, chapattis, vegetables are the best and the cheapest sources of nutrition which is in no way harmful for the child.‖ Similarly, Dr. Verma is of the opinion that hygiene is highly important for preventing pneumonia in children. Hence children should be handles only after proper hand washing. They should be dressed in clean and fresh

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clothes. It is advisable to use a large no. Of clothes and if there are only a few dresses then they should be washed frequently. According to the WHO good nutrition plays a very important role in preventing childhood pneumonia. During the first six months after birth mother‘s milk is complete and adequate nutrition for the child. It is a source of natural immunity that not only provides complete nutrition but also builds up the body‘s disease resistance. Hence by providing good nutrition and a clean hygienic environment to children we can protect them from not only pneumonia but several other infectious diseases. For this mother‘s milk is complete food for the first six months. From 6-24 months it can be supplemented with pulses, rice, chapattis, vegetables, porridge and other whole meals. There is lack of awareness among masses. There is need to mobilise them in this regard. When people will follow this regime children will be protected from pneumonia and other diseases.

Rahul Kumar Dwivedi – CNS
(Translated by Somya Arora)

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THEME 3
Importance of indoor air pollution (cook stove, tobacco smoke) in preventing pneumonia and other diseases

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Smoke-free Indoors For Pneumonia Free Lungs
Every 20 seconds, somewhere a child dies from pneumonia. Pneumonia accounts for 20% under 5 child mortality, killing 1.5 million children per year. This loss of life is even more painful because these deaths are preventable with sufficient interventions. The World Health Organization (WHO) lists several environmental factors that increase a child's susceptibility to pneumonia. These are (i) indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung); (ii) living in crowded homes; and (iii) parental smoking. It also suggests that addressing environmental factors such as indoor air pollution, by providing affordable clean indoor stoves and encouraging good hygiene in crowded homes, can reduce the number of children who fall ill with pneumonia. Pneumonia can be spread in a number of ways. The viruses and bacteria that are commonly found in a child's nose or throat can infect the lungs if they are inhaled. They may also spread via air-borne droplets from a cough or sneeze. Hence improvements in the living environment to reduce the spread of germs play an important role in pneumonia control. In 2009, WHO and UNICEF launched the Global Action Plan for the Prevention and Control of Pneumonia The World Health Organization (GAPP), to accelerate pneumonia control with a combination of (WHO) lists several interventions to protect, prevent, and environmental factors that treat pneumonia in children. Interventions that can protect children increase a child's susceptibility from pneumonia include promoting to pneumonia. These are: exclusive breastfeeding and hand washing, and reducing indoor air pollution. New technologies can reduce (i) indoor air pollution indoor air pollution. These include caused by cooking and changes in cooking fuel from traditional fuel wood, animal dung and coal (which heating with biomass are still used in several low income fuels (such as wood or countries) to liquid fuels like kerosene, dung); natural gas, LPG, etc. Relative risk reduction has been observed in specific settings with liquid fuel stoves and (ii) living in crowded improved solid fuel stoves.

homes; and

(iii) parental smoking.

Passive smoking is the inhalation of smoke, called second-hand smoke (SHS) or environmental tobacco smoke (ETS), from tobacco products used by

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others. Exposure to second-hand tobacco smoke causes disease, disability, and death. It also leads to Impaired respiratory function and slowed lung growth. In the United States, second hand smoke has been associated with an estimated 150,000 --300,000 lower respiratory tract infections in infants and children under 18 months of age, resulting in 7,500-15,000 hospitalizations each year.

Exposure to second-hand tobacco smoke causes disease,

Dr SN Rastogi, a leading Paediatrician and Child Cardiologist of Lucknow, warns that, ―Use of hookah, leads to Impaired bidi, and cigarettes in the house is quite harmful for respiratory the child. This is passive smoking as the child inhales the nicotine present in the room which increases the function and risk of pneumonia. The father /family members of slowed lung the baby should not smoke in the child's room. The new born baby should be kept in a separate room and growth less number of people should be allowed to visit and/or handle her. But in India, due to cultural norms, it is very difficult to curb this practice. From the very first day the child is born, he/she is toyed by a lot of people, which is not a good habit. This social custom, which is prevalent even in well educated families, should be stopped. Only the mother and the attendant should be allowed to get close to the child for at least the first six months.‖ The environment of the child and the pollution to which he/she is exposed play an important role in predisposing a child to a host of diseases. Dr SK Sehta, Consultant Paediatrician and Neonatologist, Lucknow, emphasizes that, ―If the home is well ventilated, sunny and airy, and the number of persons is less i.e. there is no overcrowding, so that the child has a separate and sufficient amount of space, then there is comparatively less chance of cross infection. But, if the child‘s surroundings are such that a large number of people are congested in a small room and the environment is polluted with either cooking smoke or tobacco smoke then the chances of infection are high. In such families the chances of chronic bronchitis and tuberculosis is very high which can be transmitted to the child.‖

disability, and death. It also

Tobacco smoking is a

Supporting the correlation between major cause of indoor air tobacco use and increased incidence of pneumonia, Dr Neelam Singh, pollution, and children who Consultant Obstetrician and live in an environment where Gynaecologist and Chief Functionary of Vatsalya Resource Centre on parents are tobacco smokers, Health, says that, ―Indoor air are under pollution definitely increases the risk of pneumonia. In rural areas food is cooked on chulhas so a lot of smoke results. Tobacco smoking also plays an important role in causing childhood pneumonia and other respiratory diseases. Tobacco smoking is a major cause of indoor air

high risk

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pollution, and children who live in an environment where parents are tobacco smokers, are under high risk. As far as possible, the child should be kept in a clean and pollution free environment. Air pollution in urban areas is very high which affects children‖ Dr Rastogi also agrees that as the urban population cooks mostly on gas stoves, so the pollution is comparatively less. But in rural areas people still use fuel wood and coal for cooking which causes a lot of indoor air pollution. In rural areas there is also lack of education about hygiene and cleanliness. But in urban areas people are a little more aware and so they are cautious. Dr SK Sehta, says that, ―In order to reduce indoor air pollution the government is encouraging use of cooking gas. This will reduce indoor air pollution. A law against tobacco smoking has already been enforced which prohibits smoking in community areas where people have gathered. Parents need to understand that when they are smoking indoors their child is exposed to passive smoking. So if they do not smoke at all, it would be wonderful, but at least they should not smoke before their children.‖ There is a general consensus amongst the doctors that a clean smoke free environment and no cigarette smoking around the child can reduce indoor air pollution to a large extent. Reduction in other forms of air pollution and other kinds of pollution is highly recommended because ultimately the infection has its source in some form of pollution. Strategies to reduce indoor air pollution should be encouraged, as they are likely to prevent and control pneumonia.

Somya Arora – CNS

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Environmental Burden Can Weigh Down Your Child's Health
Environmental burden is a threat to children and a risk factor for both acute and chronic respiratory diseases. While second-hand tobacco smoke and certain other pollutants are known risk factors for acute respiratory infections indoor air pollution from biomass fuel is also one of the major contributors to the global killer of children i.e. pneumonia. In fact, in developing countries, indoor pollution increases the risk of pneumonia by about 38%. According to World Health Organization (WHO), nearly half of the deaths among children under five years old from acute lower respiratory infections (ALRI) are due to particulate matter inhaled from indoor air pollution from household solid fuels. Among these deaths, 44% are due to pneumonia. Around 3 billion people still cook and heat their homes using solid fuels in open fires and leaky stoves. About 2.7 According to World billion burn biomass (wood, animal dung, crop waste) and a further 0.4 billion use Health Organization coal. Most are poor, and live in developing (WHO), nearly half of the countries. Such cooking and heating produces high levels of indoor air pollution deaths among children with a range of health-damaging pollutants. under five years old from In poorly ventilated dwellings, indoor smoke can be 100 times higher than acute lower respiratory acceptable levels for small particles. More infections (ALRI) are due than 1 million people die every year from chronic obstructive respiratory diseases to particulate matter (COPD) that develop due to exposure to inhaled from indoor air such indoor air pollution. It is particularly high among women and young children, pollution from household who spend a lot of time near the domestic solid fuels. Among these hearth. Dr Vijaya Mohan, Senior Pediatrician, pneumonia. Vivekananda Polyclinic and Institute of Medical Sciences, said that "In the villages cooking may lead to indoor pollution as they cook on 'chulha' and this leads to carbon dioxide emission. And in the cities lifestyle things like carpets and inadequate ventilation may predispose the child to respiratory infections."

deaths, 44% are due to

Urban indoor pollution may also occur due to limited spacing plan, use of synthetic materials for building and furnishing, use of chemical products, and presence of mites and cockroaches in the house. Dampness, overcrowding, and small particulate matter/pollutants present in indoor

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smoke inflame the airways and lungs, impairing the immune response and reducing the oxygen-carrying capacity of the blood. They are the most common reasons for causing pneumonia and associated mortality in young children. About 20% of all deaths in children under 5 years are due to Acute Lower Respiratory Infections, 90% of which are due to pneumonia. Passive smoking is another reason for the increased incidence of ARI in children. There is no safe level of exposure to secondhand smoke and children are exposed to it more than adults. Not only is a child's body still developing physically, but her breathing rate is also faster than that of adults. The immature immune systems and narrow airways of infants and young children make them more susceptible. Every year, an estimated 150,000 to 300,000 children under 18 months of age get pneumonia or bronchitis from breathing secondhand tobacco smoke. Research has shown that children, who grow up in a smoky household, where one or both parents smoke, are likely to have twice the amount of respiratory and lung disorders as compared to children in non smoky households. Also, mothers who smoke may contribute to inadequate breast milk production. According to Dr Jyotsna Mehta, Senior Gynaecologist and Obstetrician at Sahani and City Hospital: ―In urban societies that we are dealing with, smoking has become rampant. We promote patients to quit smoking. It should be strictly avoided during the pregnancy. It must be ensured that the child does not ever become a passive smoker, whether in the womb or outside it."

The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first international treaty negotiated under the auspices of the WHO. It was adopted by the World Health Assembly on 21 May 2003 and entered into force on 27 February 2005. It has since become one of the most rapidly and widely embraced treaties in United Nations history.

Unfortunately, finding an affordable solution for controlling indoor air pollution by reducing smoke exposure, reducing fuel costs, and attaining sustainability is a complex and evolving process. The WHO is preparing new indoor air quality guidelines for household fuel combustion. Introducing cleaner fuel, better ventilation by enlarging windows, and adding smoke hoods over the cooking area are interventions that can reduce pneumonia risk. Changing to full-scale cleaner household fuel could lower pneumonia incidence by 50%. The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first international treaty negotiated under

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the auspices of the WHO. It was adopted by the World Health Assembly on 21 May 2003 and entered into force on 27 February 2005. It has since become one of the most rapidly and widely embraced treaties in United Nations history. The WHO FCTC was developed in response to the globalization of the tobacco epidemic and is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. The Convention represents a milestone for the promotion of public health and provides new legal dimensions for international health cooperation. The WHO FCTC further drives the need for clearer guidance on protection from secondhand smoke. Children should be especially kept away from smoke. Smoke may not directly cause pneumonia, but it certainly leads to some ciliary dysfunction which may actually cause predisposition to the colonization of bacteria and viruses and make children more susceptible to pneumonia. The major interventions can be a switch at the household level to cleaner gaseous or liquid fuels; better combustion ventilation through high-quality biomass stoves; and strict self control on indoor smoking—all in the interest of our children‘s health. In the words of Professor (Dr) YC Govil, Professor, Department of Paediatrics, Chhatrapati Shahuji Maharaj Medical University (erstwhile King George‘s Medical College), Lucknow: ―The biggest intervention that can be done is education. No measure is better than awareness and for that people need to be educated about the havoc which tobacco and fuel smoke can wreak on innocent infants and children, exposing them to pneumonia related complications, (which may even be fatal) for no fault of theirs.‖

Shikha Srivastava - CNS

―The biggest intervention that can be done is education. No measure is better than awareness and for that people need to be educated about the havoc which tobacco and fuel smoke can wreak on innocent infants and children, exposing them to pneumonia related complications, (which may even be fatal) for no fault of theirs‖
- Professor (Dr) YC Govil, Department of Paediatrics, CSMMU

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Passive smoking and lack of hygiene

breeds childhood pneumonia
Hygiene and cleanliness should be maintained within the households and children should not be exposed to tobacco smoke or smoke coming out of cook stoves. Passive tobacco smoke is not only harmful for health but also puts children at high risk of contracting pneumonia. "Cleanliness and hygiene is very important for controlling pneumonia especially in children. In our country there is a tradition to put kohl (kajala) in the eyes of the children, give them oil massages, etc. We need to be very cautious regarding hygiene when it comes to children as their immunity is still developing" said Dr KN Dwivedi, noted Paediatrician from Gorakhpur. "Children of ages 7-10 years are likely to be smoking beedi or eating 'surti'

tobacco in the urban slum I live in Gorakhpur" said Pradeep Srivastava, a father of a child with pneumonia. "It is difficult to protect children from being exposed to second hand tobacco smoke because of two reasons: our slum dwelling is so small and tobacco use is high and secondly, people are not aware that second hand tobacco smoke can put one's child at risk of pneumonia" said Srivastava.

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Speaking to two mothers of newly born infants we realized that both of them were not aware of the dangers of second hand tobacco smoke. They weren't aware about the fact that second hand tobacco smoke can put a child at risk of contracting pneumonia among other serious health hazards. One of the two mothers was herself eating 'surti' tobacco. Most tobacco users in his slum consume tobacco in either 'beedi' smoking or chewing 'surti' forms, informs Srivastava. "My grandson had pneumonia. He had respiratory problems, was short of breath, pain in abdomen and fever. Doctors said that he got pneumonia due to exposure to cold weather. His mother had breastfed him for 5-6 months and then we began feeding him cow's milk. No one smokes in our house but people do eat tobacco in form of 'surti'. We cook our food on stoves by burning wood and exposure of the grandson to this smoke was there" said Indrawati, a slum resident in Gorakhpur. According to experts smoke from cook stoves or tobacco can heighten the risk of pneumonia for children. Second hand tobacco smoke is dangerous anyways for everyone and can cause life-threatening diseases and disabilities attributed to tobacco use.

In India it is estimated that about 100 million people use tobacco in form of 'beedi' (leaves rolled with tobacco). It is also estimated in a Beedi Monograph which was recently released by the Ministry of Health and Family Welfare that the

number of beedi smoking people dying of tobacco-related deaths is greater than
the number of deaths among those using tobacco in other forms

According to Professor (Dr) Rama Kant, a General’s Awardee 2005 World Health Organization (WHO) Director-General's Awardee on tobacco control: "In India it is estimated that about 100 million people use tobacco in form of 'beedi' (leaves rolled with tobacco). It is also Professor (Dr) Rama Kant estimated in a Beedi Monograph which was recently released by the Ministry of Health and Family Welfare that the number of beedi smoking people dying of tobacco-related deaths is greater than the number of deaths among those using tobacco in other forms." Prof (Dr) Rama Kant adds: "Tobacco is dangerous in all forms. Presently many states in India report alarming levels of beedi smoking such as 10.6 14.2% beedi smoking in Manipur, Mizoram, Nagaland and Sikkim; 4.6-9.2% in states of Arunachal Pradesh, Assam, Bihar, Chandigarh and Meghalaya.

Professor (Dr) Rama Kant, WHO Director-

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Mizoram has highest beedi smoking rates in India and Punjab has the lowest incidence of beedi smoking." Prof Rama Kant who is also the President-elect of Association of Surgeons of India (ASI), explains: "Beedi usually has less amount of tobacco but high amount of tar, nicotine and other harmful ingredients. There are some ingredients in beedi that greatly increase the risk of developing cancers. Beedi smokers develop life-threatening tobacco related diseases and disabilities including cancers among which oral cancer, cancer of respiratory tract, etc are very common. The beedi monograph also mentions that such tobacco related cancers constitute 75% of all cancers." Children in particular should be protected from tobacco smoke or smoke coming out of cook stoves and also be brought up in clean, hygiene and healthy environment.

Jitendra Dwivedi – CNS
(Translation: CNS)

"Beedi usually has less amount of tobacco but high amount of tar, nicotine and other harmful ingredients. There are some ingredients in beedi that greatly increase the risk of developing cancers. Beedi smokers develop life-threatening tobacco related diseases and disabilities including cancers among which oral cancer, cancer of respiratory tract, etc are very common. The beedi monograph also mentions that such tobacco related cancers constitute 75% of all cancers‖
Professor (Dr) RAMA KANT, WHO Director-General‟s Awardee 2005

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Indoor air pollution and childhood pneumonia
There is increasing awareness about harms of pollution on one‘s lungs but less on how the unborn child is harmed when her or his mother inhales polluted air. Indoor air pollution has serious consequences for the unborn child such as the smoke coming out of cook stoves or tobacco smoke. Tobacco consumption is associated with diseases, disabilities and deaths. When non-smokers are exposed to secondhand smoke it is called involuntary smoking or passive smoking. Non-smokers who breathe in secondhand smoke take in nicotine and other toxic chemicals just like smokers do. The more secondhand smoke you are exposed to, the higher the level of these harmful chemicals in your body. Passive smoking or exposure to secondhand tobacco smoke also causes serious life-threatening ailments and one of them is their adverse impact on pregnant mother. Pregnant women exposed to secondhand smoke are also at increased risk of having low birth-weight babies or still birth. According to the World Health Organization (WHO) secondhand smoke is killing 600,000 annually, including 165,000 children under the age of 5 years. Exposure to secondhand smoke or passive smoking is directly linked to lung infections such as pneumonia and bronchitis especially in children below the age of 18 months. Dr Ritu Garg, senior Gynaecologist and Obstetrician, Yash Hospital said that a child can be protected by smoke coming out of cook stoves by covering her or him by a very thin and light cloth (make sure breathing is not restricted in any way or pose any other danger to the child). However Dr Garg also points out that tobacco smoking by parents or other family members living in the house is unacceptable. Passive smoke or secondhand smoke is detrimental for a child‘s health and causes pneumonia. Awareness about hazards of secondhand smoke is low. Child of educated parents, Munindra Nath and Prabha Anand was born as a premature child

Passive smoking or exposure to secondhand tobacco smoke also causes serious life-threatening ailments and one of them is their adverse impact on pregnant mother. Pregnant women exposed to secondhand smoke are also at increased risk of having low birthweight babies or still birth. According to the World Health Organization (WHO) secondhand smoke is killing 600,000 annually, including 165,000 children under the age of 5 years.

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and later developed pneumonia. However they weren‘t really alarmed about harmful effects of exposure to secondhand smoke due to smoking cigarettes within households. Not only secondhand smoke but also other dust particles arising out of construction going within the house or close by or other sources is harmful for a child and puts the child at risk of asthma and pneumonia, said Dr Nidhi Johri, senior Gynaecologist and Obstetrician, Hope Mother and Child Care Centre, Lucknow. At least 40 per cent of childhood pneumonia cases among her patients are due to secondhand smoke, said Dr Johri. Environmental pollution is dangerous in every way and particularly a lead cause of respiratory infections such as pneumonia in children with low immunity, said Dr Ajay Kumar, senior Paediatrician, Hope Mother and Child Care Centre, Lucknow. When immunity of a child is low then the child is at an elevated risk of contracting such infections like pneumonia. Exposure to smoke of ‗bidi‘ or cigarettes is very bad for a child‘s health, said Dr Santosh Rai, senior paediatrician, Vatsalya Clinic, Lucknow. Dr Rai adds that parents should protect their children from smoke coming out of other sources too apart from cook stoves and tobacco – such as mosquito repellant coils which might be dangerous for their child. Children should not be exposed to smoke coming out of cook stoves. Either the cooking can be done on cook stoves away from where the child is or some other practical solution needs to be worked out. Similarly for those parents or other guardians smoking tobacco inside the house it is strongly recommended not to do so anymore and best is to quit tobacco use before it gets too late and tobacco-related life-threatening diseases take their course.

Neeraj Mainali – CNS
(Translation: CNS)

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Second-hand tobacco smoke increases risk for childhood pneumonia
Indoor air pollution increases the risk for childhood pneumonia. Smoke coming out of cook stoves and second-hand or third-hand smoke that is a direct result of family members smoking tobacco within households also scales up the risk for childhood pneumonia. Since pneumonia adversely affects the lungs, indoor air pollution and inhaling tobacco smoke or smoke coming out of cook stoves puts children at risk of pneumonia. ―In villages people cook their food by burning wood as cooking gas is usually not available in remote areas of rural India. Also dust within the house or animal furs at times also puts children at risk of infections. We should keep our houses clean and dust-free, reduce indoor air pollution and refrain from smoking tobacco especially within the house to protect the child from respiratory infections such as pneumonia‖ said Dr Abhishek Verma, senior Paediatrician, Dr Ram Manohar Lohia Hospital in Gomti Nagar, Lucknow. Dr Verma adds: ―Smoking cigarettes or ‗beedi‘ or other smoking forms of tobacco increases the risk of pneumonia and other conditions such as asthma. Indoor air pollution can also be reduced by cooking food using cooking gas stoves instead of burning wood for example, or keeping the child away from smoke-filled areas. We should sweep our floors to reduce dust in the indoor air. Also protecting your child from fur of pet animals is advisable. Using mosquito nets is also strongly recommended to keep one‘s child and family healthy.‖ ―We should not expose young children to smoke coming out of cook stoves or tobacco smoke. Smoke fills up the lungs of the child and makes her or him very vulnerable to a range of infections such as pneumonia. It is advisable that we should move the children away when cleaning the house so that they don‘t get exposed to dust. Also floor of our houses should be sweeped with water mixed with phenyl or ‗neem‘ leaves‖ said Dr Rama Shankhdhar, senior Gynaecologist and Obstetrician in Indira Nagar, Lucknow. Agrees Dr RS Dubey, Chief Medical Superintendent (CMS) of Dr Ram Manohar Lohia Hospital in Gomti Nagar, Lucknow: ―second hand tobacco smoke has a definite adverse impact on one‘s health, and the harm is more pronounced 65 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

in children. Children who are exposed to tobacco smoke passively inhale the tobacco smoke in and this is clearly not good for their health.‖ Due to exposure to indoor air pollution, daughter, Tulsi, of a slum resident Rekha developed pneumonia. Rekha, mother, wasn‘t even aware that smoke of cook stoves can increase the risk of pneumonia for her daughter. She holds her child in her arms while cooking food on the stove. Her husband also smokes ‗bidi‘ within the house or in close proximity of the child the adverse health effect of which is evident with the child developing pneumonia. The treating doctors haven‘t advised yet to keep their child away from tobacco smoke or smoke coming out of cook stoves. Despite pneumonia is preventable and curable still it continues to remain the single largest cause of under-5 years of age child mortality. To protect one‘s child from pneumonia and other lung or respiratory tract infections it is vital that we keep our homes clean of indoor air pollution caused by tobacco smoking or cook stoves or other factors.

Nadeem Salmani – CNS
(Translation: CNS)

Mother and child with pneumonia, in slums, behind Dr RML Hospital, Gomti Nagar, Lucknow

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Indoor Air Pollution increases the risk of Childhood Pneumonia
Indoor air pollution from tobacco smoke, cooking smoke from fuel wood and cow dung based chulhas plays an important role in predisposing children to pneumonia. According to the World Health Organization (WHO) environment related pollution like cooking on burning wood or cow dung or other organic fuels, smoking indoors, living in crowded homes, all increase the risk of pneumonia in children. Thus children must be kept in a clean and hygienic environment so that the risk of getting pneumonia and other infections is minimal. According to Dr KK Verma, Senior Paediatrician, District Hospital, Bahraich, ―Indoor air pollution like smoking ‗bidis‘, cooking on chulhas, etc, increase the risk of pneumonia. There Indoor air are a host of other sources of indoor air pollution in pollution from rural areas. The kitchen in villages is made of kutcha walls which increases the risk of spread of tobacco smoke, infections. The kitchen should be made outside the cooking smoke space where the child lives and should be constructed of ―pucca‖ walls. Children in villages from fuel wood generally feed while sitting on the floor. This and cow dung practice should be avoided. Homes should be regularly whitewashed. Homes should be made of based chulhas ‗pucca‘ bricks. Urban people have less chances of contracting infections because they have access to plays an important clean drinking water. Rural masses do not have this role in facility which increases manifold the risk of pneumonia.‖ According to Dr. Kumud Anup, Private practising Paediatrician, Lucknow, tobacco smoking is the main cause of indoor air pollution. She opines, ―In urban areas tobacco smoke is a major source of indoor air pollution. Children are exposed to passive form of smoking which is extremely dangerous and increases the risk of pneumonia. Tobacco smoking greatly increases the susceptibility to not only pneumonia but also asthma and several other infections. Hence to protect children from the ill-effects of passive smoking, smoking should be strictly prohibited inside homes. This will help contain the chances of pneumonia and other related illnesses. Even among the medical community there is lack of awareness about the relation between indoor air pollution and infections. This was gathered from the opinion of Dr PK Mishra, Gynaecologist, District Hospital, Bahraich, who does not consider indoor air pollution to be a factor in increasing risk of childhood pneumonia. According to him, ―Tobacco smoking or cooking on

predisposing children to pneumonia

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chulhas does not directly increase risk of pneumonia. Although it can suffocate the child but does not lead to any infection.‖ Tobacco smoking increases the risk of pneumonia. This can be estimated from the survey of pneumonia patients at the Bahraich District Hospital. The mother of a two and a half year old child suffering from pneumonia told that many members of her family smoke and use other tobacco products. Also food is cooked on a chulha. Another three day old child sufferer‘s mother told that food is cooked on chulha in her home and that the child‘s father uses tobacco in the form of cigarette, ―bidi‖ and ―gutkha‖. Better healthcare, proper nutrition and improvement in environment are the factors that can independently lead to decrease in deaths due to childhood pneumonia. Thus these factors play an important role in the upliftment of the living standard of society. The Government should take into consideration these factors before the implementation of health programmes. Improvement in the standard of living and the adopting healthy and hygienic practices will together lead to the decrease in the incidence of childhood pneumonia and other infections.

Rahul Kumar Dwivedi – CNS
(Translation: Somya Arora)

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THEME 4
Access to affordable vaccines in our communities to prevent childhood pneumonia

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Vaccine Shots Can Combat The Death Shot Of Pneumonia
It is unfortunate that pneumonia is the world's leading killer of young children despite the fact that possible medications and immunizations for the disease are available. Then why are our children being held hostage by pneumonia? The possible reasons could be unavailability/unaffordability of medication and/or lack of information. Realizing that reducing child deaths from pneumonia is the need of the hour, the Global Action Plan for the Prevention and Control of Pneumonia (GAPP) has come up with recommendations on specific goals and targets to reduce mortality from pneumonia. It also aims that every child is protected against pneumonia through a healthy environment, and has access to preventive and treatment measures. In the words of Dr Margaret Chan, Director-General of World Health Organization (WHO), "This action plan provides the strategy to prevent and control pneumonia, which today kills more children than any other illness,"

… preventing
children from becoming ill with pneumonia (with vaccination against its causes:

The GAPP‘s simple three-pronged vision of "protect, prevent and treat" has the potential to save more than a million children who die of pneumonia each year. (i) Protecting every child by providing an environment where they are at low risk (ii) Preventing children from becoming ill with pneumonia (with vaccination against its causes: measles, pertussis, Streptococcus pneumoniae and Haemophilus influenzae b) (iii) Treating children who become ill with pneumonia with the right care. This strategy is hoped to lead to a reduction in child pneumonia deaths by 65% and cut the number of severe pneumonia cases in children by 25%. GAPP's vision-Pneumococcal vaccine uptake will be gradual and in some countries it will only be introduced in 2014, thus 90% coverage by 2015 will not apply to it.), Easy4, Hibirix, tetrad Hib (4% reduction in all child deaths with Hib.

measles, pertussis, Streptococcus pneumoniae and Haemophilus influenzae b)

In the context of child survival strategies, countries should address pneumonia control by way of vaccinations and health care programmes. As pneumonia is caused by various organisms like- Pneumococcus, Sreptococcus, Haemophilus influenzae or Mycoplasma etc, the vaccine is guided by the type of organisms causing pneumonia. So there are a number of vaccines available, like Pneumococal Vaccine and the Haemophilus influenzae or Hib Vaccine.

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Others include the BCG vaccine for tuberculosis, DPT vaccine for diphtheria and pertusis which are the infections of the upper respiratory tract, and measles vaccine which indirectly prevents pneumonia, because a child with measles becomes very weak and is more prone to the super added infection of pneumonia. Three doses of Hib vaccine along with DPT are effective against Haemophilus influenza (which is a very virulent bacterium and responsible for a highly fatal pneumonia in children) and reduce incidence of mortality among children by 22%–34%. WHO has urged that countries with high rates of mortality in children aged under 5 years, and countries with a high prevalence of HIV, should consider introducing pneumococcal conjugate vaccines into the national immunization program and Hib vaccine for infant immunization in all countries. But as of now, this is only implemented in the developed countries while the developing countries are still striving for it. GAPP's vision is that the Pneumococcal Vaccine uptake will be gradual and in some countries it may only be introduced in 2014. Negligence and lack of education play another important role in boosting pneumonia. The WHO, Global data bank on infant and child pneumonia reveals that only 82% of children receive their first routine dose of a vaccine against measles. Not all countries have introduced Hib vaccination, although there has been recent progress in this area. Few countries have yet not included the pneumococcal conjugate vaccine in their national immunization programmes, though there is strong interest in many countdown countries to do so. Low coverage prevails for other interventions also, and it is usually the children at greatest risk of pneumonia, who are not covered. These life saving vaccines come with a high price tag and are not pocket friendly. Hence it becomes difficult for the common masses to afford them. It is for this reason that they are not included in the Government health care programmes in India. According to Dr Vijaya Mohan (Consultant Pediatrician, Vivekananda Polyclinic and Institute of Medical Sciences) "The affluent class can afford the vaccine but the problem of common masses is that it is costly."

"If I ever

knew that there is a vaccine available against pneumonia, I
would have made all efforts to get my child vaccinated to prevent him from such dreadful conditions as he is facing now"

Another important hurdle in preventing pneumonia is - Mother of a the lack of information. The general public is mostly child with not aware of these vaccines, as they are not mentioned in the government health care programme. pneumonia The mother of a three years old child Atharva, who was admitted in Chhatrapati Shahuji Maharaj Medical University with acute pneumonia, said, "If I ever knew that there is a vaccine available against pneumonia, I would have made all efforts to get 71 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

my child vaccinated to prevent him from such dreadful conditions as he is facing now." The achievement of the global objectives for pneumonia prevention and control will require coordination among the concerned individual programmes at country and regional levels and expanded support from development agencies.

Shikha Srivastava – CNS

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Life Saving Shots For Killer Pneumonia
Each year, millions of children succumb to diseases like pneumonia which are preventable with readily available vaccines. Pneumonia is the leading killer of children under 5 claiming 1.5 million young lives every year. Despite being the cause of almost 20% of all under 5 deaths, the disease attracts less than 5% of the global health funding. Vaccines against two of the main causes of life-threatening pneumonia— pneumococcal (Streptococcus pneumoniae) and Hib (Haemophilus influenzae Type b) have been developed and are currently being used in the developed countries. But coverage in third world countries like India (which accounts for almost 40% of the worldwide childhood pneumonia cases) is low, particularly of pneumococcal vaccines. If developing countries had these vaccines, the lives of almost 1 million children under age 5 could be saved every year. Immunization protects children from pneumonia, which is a debilitating disease that can often lead to complications like chronic respiratory conditions and septicaemia or the likelihood of a fatal outcome. All children have the right to this protection. The WHO immunization schedule for infants recommends that children receive Hib and Pneumococcal conjugate vaccine (PCV) in 3 doses over a period of the first 6 months. However whereas vaccination with Hib is included in the immunization programme of many countries, the PCV is presently available only in some countries.

If developing countries had these vaccines, the lives of almost 1

Pneumococcal Vaccines Accelerated Development and Introduction Plan (PneumoADIP) is a project funded by Global Alliance for Vaccines and Immunisations (GAVI) to accelerate the introduction of pneumococcal vaccinations into low-income countries through partnerships between countries, donors, academia, international organizations and industry. With action now, a projected 5.4 million child deaths can be prevented by 2030.

million children under

age 5 could be saved every year

Haemophilus influenzae type B vaccine (Hib janan or PRP vaccine) is a conjugate vaccine developed for the prevention of fatal invasive pneumonia. Due to routine use of the Hib vaccine in the U.S. from 1980 to 1990, the incidence of invasive Hib disease decreased from 40-100 per 100,000 children down to 1.3 per 100,000. GAVI offers substantial subsidization of Hib vaccine for developing countries. In addition, GAVI has created the Hib Initiative to catalyze uptake of the vaccine. The CDC and

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WHO currently recommend that all infants be vaccinated using a polysaccharide-protein conjugate Hib vaccine, starting after the age of 6 weeks. Dr SK Sehta, a Consultant Paediatrician and Neonatologist of Lucknow hopes that, ―Although these vaccines are very expensive presently, the Government of India is planning along with the W.H.O. to make the Hib vaccine available in developing countries like ours. However, these have a very low affordability in the masses. Other vaccines that are a part of the W.H.O. recommendations, for example measles, are very important as measles increases susceptibility to pneumonia.‖ Similarly, Dr Neelam Singh, Consultant Paediatrician and Gynaecologist and Chief Functionary of Vatsalya Resource Centre on Health, says, ―The BCG vaccine against tuberculosis is very important. Many respiratory diseases and infections in children are caused due to tuberculosis. Secondly, we have the DPT vaccine for diphtheria, pertusis and tetanus, out of which the first two are infections of the upper respiratory tract. Thirdly, measles vaccine given at nine months is very important. Although the measles vaccine does not directly prevent pneumonia but indirectly it does, because a child suffering from measles becomes prone to the super added infection of pneumonia. So this vaccination programme should be followed regularly from birth to twelve years of child‘s age. Recently the Hib vaccine has been introduced. Three doses of this vaccine are given along with DPT. It is available in our country. Urban people who can afford it as it is an expensive vaccine get their children immunized.‖ The aforementioned vaccines prevent fatal pneumonia caused by highly virulent strains of the most common pathogens. However, a child vaccinated is not cent percent safe from pneumonia. This fact needs to be understood by parents and caretakers. Immunization is not fool proof. Proper hygiene along with good nutrition is also a vital component of the pneumonia prevention strategy. In this context Dr SN Rastogi, Paediatrician and Child Cardiologist, running a private clinic in Lucknow adds, ―Pneumonia can be caused by various pathogens like- Streptococcus pneumoniae or Haemophilus influnzae or Mycoplasma. Parents think that if once they have got their child vaccinated she/he won‘t be affected by pneumonia. But pneumonia can occur as secondary infection also.‖ Due to lack of public awareness and the high cost of these life-saving vaccines, several children in India are not able to avail of their benefits. One of them is Atharva, a 3 years old child, who was battling for his life in the Paediatric Intensive Care Unit of Chattrapati Sahuji Maharaj Medical University, when I visited him in the first week of October, 2011. His mother, Mrs. Renu Bala Sharma, lamented, ―We had heard that pneumonia is a common disease of children and children do get infected with it often but we had never thought it would get so serious. We got him vaccinated against every disease. We went by the vaccination card. We did not know whether it had pneumonia vaccine also in it. Had we known about the vaccine we would have got him immunized. Money isn‘t more precious than 74 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

our child. We have already spent lakhs of rupees on his treatment. We were driven from one nursing home to another, and had almost given up on him, till we reached this hospital. Now there is some hope of his recovery. ‖ The pneumonia vaccines are not yet a part of the immunization programme in India and many other developing nations. Ironically these are the nations where the prevalence of pneumonia is very high. Of course, well educated mothers of the upper strata of Indian society make sure that their child is immunized against every life threatening disease. Mrs. Alpana Singh, who gave birth to her second child on the 1st October at the private City Hospital, Lucknow, says, ―I have heard that pneumonia is one of the most dangerous diseases. I cannot recall the name of the vaccine, but my doctor told me about it and I got my first child, who is three years old now, vaccinated against it as a precautionary measure. But the vaccine was not mentioned on the regular vaccination chart.‖ The WHO actively works towards mobilizing parents and other caregivers about why immunization is important, the recommended immunization schedule, and where their children can be immunized. There is an imminent need for Research and Development initiatives in the development of pneumonia vaccines. With support and funds from international organizations, these vaccines should be made available, at affordable costs, in developing countries at the earliest.

Somya Arora – CNS

―We had heard that pneumonia is a common disease of children and children do get infected with it often but we had never thought it would get so serious. We got him vaccinated against every disease. We went by the vaccination card. We did not know whether it had pneumonia vaccine also in it. Had we known about the vaccine we would have got him immunized. Money isn‘t more precious than our child‖
- Mrs Renu Bala Sharma, mother of Atharva, a 3 years old child, who was battling for his life in the Paediatric Intensive Care Unit of Chattrapati Sahuji Maharaj Medical University, when CNS visited him in the first week of October, 2011

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A Shot In Arm Prevents Children From Pneumonia
Pneumonia, the leading global killer of children under five, is a disease that occurs most commonly when a child‘s still-developing defence system is weakened by malnutrition, air pollution, co-infections with HIV/AIDS and measles, and low birth weight. Appropriate therapies will cure most cases of paediatric bacterial pneumonia. But many children go untreated, and as a result as many as 20% of them die, sometimes within 3 days of onset. It is no wonder then, that pneumonia is responsible for almost 1.6 million deaths per year, which is about one-fifth of all paediatric deaths around the world. Apart from breastfeeding and improved living conditions, access to vaccines and antibiotics, and timely treatment can dramatically reduce deaths from childhood pneumonia in developing countries. Vaccines to prevent diseases associated with streptococcus pneumonia and Haemophilus influenza type b are remarkably ―Some vaccines, like effective. Children in countries without these vaccines are 40 times more likely to die than the Hib vaccine, are those in countries where they are routinely good and a must, administered. Wider use of measles vaccine which should be given (which covered 75% of the world‘s children in 2004) can also lessen paediatric pneumonia routinely. The significantly, as pneumonia can cause death pneumococcal vaccine among the 30 to 40 million children infected by is another good measles every year.

vaccine. But the issue is whether the strains causing the disease, which are present in the community, are the same as those present in the vaccine‖

Professor (Dr) Gourdas Choudhuri, Professor and Head, Gastroenterology Department, Sanjay Gandhi Post-Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, while acknowledging that the role of vaccines in preventing the disease cannot be overlooked, raises a few pertinent points regarding the issue. According to him, ―Some vaccines, like the Hib vaccine, are good and a must, which should be given routinely. The pneumococcal vaccine is - PROFESSOR (DR) GOURDAS another good vaccine. But the issue is whether CHOUDHURI, Professor and the strains causing the disease, which are present Head, Gastroenterology in the community, are the same as those present Department, Sanjay Gandhi Postin the vaccine. Otherwise the vaccine will not Graduate Institute of Medical work, and the money spent will not get the Sciences (SGPGIMS), Lucknow protection one is expecting. Pneumococcus, one of the germs that cause pneumonia in children, has many strains. The vaccine, which is currently available, has strains that are found chiefly in the western world, and its profile does not match with the strains found in our country. So a routine immunization with one vaccine may not work. As

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pneumonia, a serious infection of the lungs, can be caused by several germs—pneumococcus bacteria, influenza virus, swine flu virus, etc—a vaccine will work well against some of these but not all. So it is difficult to have a single complete vaccine for full protection.‖ Pneumococcal conjugate vaccine (PCV13) protects against 13 out of the 20 most common pneumococcal strains known as serotypes; and reduces hospital admissions linked to child pneumonia by almost 40%. As of 2008, around 31 countries had introduced the pneumococcal vaccine and 15 others had applied for support from The Global alliance for Vaccines and Immunisation (GAVI) to fund the vaccine. Hib vaccine (Haemophilus Influenzae type b) is another highly effective vaccine and 136 countries have introduced it either nationwide or partly, and 102 countries have introduced it widely. 42 million children had received the vaccination. The vaccine is not routinely available in India (and many Asian countries), although available in Central and South America and most of Africa. In low income countries pneumonia kills 7320 out of 1000000 children under age 5, as compared to just 34 children in high income countries. Poverty remains a persistent barrier to immunization at the country and community levels. Mere availability of the pneumonia vaccines in the private pharmaceutical market does not ensure its use, primarily because of the prohibitive costs and also because of lack of information. 93% of the world‘s children—121 million—had not received a pneumococcal vaccine and 71% or 93 million children had not received the Hib vaccine as of 2008. According to Dr Dinesh Chandra Pandey, a Specialist in Paediatric Medicine at Nelson Hospital of Paediatrics and Neonatal Medicine, Lucknow, ―Many multinational pharmaceutical companies are producing pneumonia vaccines, but their costs are prohibitively high and common public cannot afford them. Such a situation cannot work in India where 80% of the population lives in villages and is poor. So where the incidence of disease is high, availability of medicines is poor. Vaccines like Preminar strepto pneumonia are available in the market, but are very costly. The Hib Influenza vaccine, which prevents pneumonia, is not available in government programmes. Another influenza vaccine for prevention of HINI flu is also not there at affordable prices.‖ Dr Ajay Misra, Managing Director of Nelson Hospital of Paediatrics and Neonatal Medicine, Lucknow, also airs similar views. He laments that ―There are no pneumonia vaccines included in the government public health 77 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

immunization programmes. Although pneumococcal vaccines available in the market, but they are very costly. Many people are not even aware of the vaccines available in the market.‖ Timely access to medical care, including vaccines, and proper awareness of the disease is an important issue in increasing the survival rate of children from childhood pneumonia and other diseases. The burden of vaccine preventable diseases falls on the poor. According to the Acute Respiratory Infections Atlas, broader use of the Hib vaccine could save 400,000 lives, and the pneumococcal vaccine could prevent 262,000 deaths a year in 72 of the world‘s poorest countries. The GAVI is spearheading international efforts to increase access to pneumonia vaccines. It currently funds immunization campaigns in 72 low income countries. Millions of lives can be saved by 2015 if GAVI could implement its $7 billion campaign to distribute three vaccines: a 5 in 1 vaccine against Hib disease, diphtheria, tetanus, pertusis and hepatitis B; pneumococcal vaccines and vaccine to prevent rotavirus diarrhoea. But as of 2010, the organization had a shortfall of $3 billion, to implement its noble objectives. Increasing immunization will depend not only upon availability of vaccines but also on a strong vaccine delivery infra structure, leadership and political will to integrate immunization programmes with other healthcare services, community awareness about the value of vaccines, and a much greater commitment from the international community to make universal immunization against childhood pneumonia and other diseases a dream come true for the indigent populations.

Shobha Shukla - CNS

Timely access to medical care, including vaccines, and proper awareness of the disease is an important issue in increasing the survival rate of children from childhood pneumonia and other diseases. The burden of vaccine preventable diseases falls on the poor

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Pneumonia vaccination not reaching children who need it most
Although pneumonia continues to be the biggest cause of under 5 years of age mortality for children yet its vaccination is not included under the public health programme of the Government of India. Most people who get their children vaccinated have to buy it from the private sector. Most alarming human rights issue is that the children who are likely to need it most or those children who are most at risk of pneumonia, are the ones least likely to be able to afford a pneumonia vaccine. These most-at-need children at times come from poor families and are brought up in surroundings that lack hygiene, lack cleanliness, are overcrowded, are often malnourished, and more likely to be exposed to second hand tobacco smoke or smoke coming out of cook stoves. Also these most-at-risk children for pneumonia are coming from families with low levels of health literacy.

"One child in my family also got pneumonia. In the urban slums we live in, most people are taking their children for immunization in government hospitals. The vaccines are provided free by the government. However there are still some people who are not taking their children for vaccination. These are the people who should be targetted by the awareness programmes and mobilized to take their children to the hospital for immunization. Last year there was a family who was not taking the child for vaccination and we convinced them about the benefits of vaccination and finally the child did get vaccinated" said Pradeep Srivastava, a resident of a slum in Gorakhpur.

Although pneumonia continues to be the biggest cause of under 5 years of age mortality for children yet its vaccination is not included under the public health programme of the Government of India

It is important to clarify that Pradeep is not aware whether children in his family got vaccinated for pneumonia or not. In reality pneumonia vaccines are not included in the national immunization programme of the Government of India. So most likely none of the children in his slum would have got vaccinated for pneumonia as it is not provided free in the government public sector healthcare facilities. Another slum resident from Gorakhpur Indravati said that one of her grandsons got pneumonia. The grandson was vaccinated in the government hospital but she wasn't aware whether pneumonia vaccine was given or not. As one can guess since pneumonia vaccine is not included in the government-run immunization programme, none of the children in the slum

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Indravati lives in would have got vaccinated against pneumonia, although they might be at a higher risk due to malnutrition, lack of hygiene and cleanliness, overcrowding and exposure to tobacco smoke or smoke from cook stoves. As is evident the government of India must respond to the growing challenge of childhood pneumonia and include vaccination in its immunization programme.

Jitendra Dwivedi – CNS
(Translation: CNS)

Most alarming human rights issue is that the children who are likely to need vaccination the most or those children who are most at risk of pneumonia, are the ones least likely to be able to afford a pneumonia vaccine

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Get your child vaccinated against pneumonia
―Pneumonia vaccination as per the standards set by the World Health Organization (WHO) is available in the market as per the causative agent. However in public sector government hospitals vaccination for pneumonia is not available‖ said Dr Abhishek Verma, senior Paediatrician, Dr Ram Manohar Lohia Hospital, Gomti Nagar, Lucknow. Pneumonia is an inflammatory condition of the lung - especially affecting the microscopic air sacs (alveoli) ―Vaccination against associated with fever, chest symptoms, and pneumonia is specific to a lack of air space (consolidation) on a chest X-ray. Pneumonia is typically caused the causative agent. As by an infection but there are a number of pneumonia can be caused other causes. Infectious agents include: by virus, fungi or bacteria bacteria, viruses, fungi, and parasites. Vaccines to prevent certain types of or other parasites, vaccines pneumonia are available. Although too are specific in pneumonia can affect any one regardless of protecting children against age but children below 5 years of age are at high risk of getting pneumonia if proper specific types of care is not taken. Children also contract pneumonia due to changing weather or exposure to cold. If children get vaccinated against pneumonia then it will at least protect them from certain types of pneumonia. The WHO has recommended pneumonia vaccination and it is available in the private healthcare settings.

―Vaccination against pneumonia is specific to the causative agent. As pneumonia can be caused by virus, fungi or bacteria or other parasites, vaccines too are specific in - Dr ABHISHEK VERMA, protecting children against specific types Paediatrician, of pneumonia. Vaccines against two of the Dr RML Hospital, Lucknow main causes of life-threatening pneumonia pneumococcal (Streptococcus pneumoniae) and Hib (Haemophilus influenzae Type b) have been developed and are currently being used in the developed countries. But coverage in third world countries like India (which accounts for almost 40% of the

pneumonia. Vaccines against two of the main causes of life-threatening pneumonia - pneumococcal (Streptococcus pneumoniae) and Hib (Haemophilus influenzae Type b) have been developed and are currently being used‖

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worldwide childhood pneumonia cases) is low, particularly of pneumococcal vaccines‖ said Dr Verma. Added Dr Verma: ―Immunization protects children from pneumonia. All children have the right to this protection. The WHO immunization schedule for infants recommends that children receive Hib and Pneumococcal conjugate vaccine (PCV) in 3 doses over a period of the first 6 months. These are not available in government public sector hospitals. In government hospitals seven vaccinations are provided which includes DPT, polio, BCG, hepatitis B among others. However if parents want their children to be vaccinated against pneumonia then they have to buy it from the private pharmacies.‖ Agrees Dr Rama Shankhdhar, senior Gynaecologist and Obstetrician, Rama Consultations and Training Centre, C-block crossing, Indira Nagar, Lucknow: ―The WHO has recommended the young infants to receive Hib and Pneumococcal conjugate vaccine (PCV) in 3 doses over a period of the first 6 months (with a difference of 1 month between every dose) and it protects children from specific types of pneumonia. Vaccine is very specific and doesn‘t provide protection against all forms of pneumonia. All precautions must be taken even after vaccination to reduce the risk factors to protect our child. Proper treatment and care should be taken of the child whenever she or he shows first symptoms such as fever or cold.‖ Pneumonia vaccines are not available in government healthcare settings. They can be easily bought from the private pharmacies but not provided free as part of the national immunization programme. ―Vaccination against pneumonia is recommended by the WHO but not available in government hospitals‖ said Dr RS Dubey, Chief Medical Superintendent (CMS), Dr Ram Manohar Lohia Hospital, Gomti Nagar, Lucknow. Probably this is the reason why three children we met in the slums behind Dr Ram Manohar Lohia Hospital in Gomti Nagar (Jyoti, Tulsi and Yasmeen) developed pneumonia as their parents couldn‘t afford to buy the vaccines from private pharmacies and other risk factors were also present in the surroundings where the slum in.

Nadeem Salmani – CNS
(Translation: CNS)

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Pneumonia vaccination: Beyond reach for most children
Despite pneumonia is the lead killer of children below the age of five years still the government has not included pneumonia vaccination in the national vaccination programme for children that is provided free of cost in the government run public healthcare service centres. According to the 2008 data, 371605 children below the age of five years died due to pneumonia which is 20.3% of all deaths occurring in the under-5 children that year. Ironically children who are at an alarming risk of pneumonia are more likely to be poor, exposed to tobacco smoke or smoke from cook stoves, live in over-crowded and polluted surroundings with low levels of hygiene or cleanliness, among other risk factors that put them at a greater risk of pneumonia. These most-at-risk children are also least likely to get vaccinated against pneumonia as their parents or guardians are least likely to be able to afford the cost. ―As pneumonia can be caused by virus, fungi or bacteria or other parasites, vaccines too are specific in protecting children against specific types of pneumonia. Vaccination against pneumonia is specific to the causative agent. Vaccines against two of the main causes of life-threatening pneumonia - pneumococcal (Streptococcus pneumoniae) and Hib (Haemophilus influenzae Type b) have been developed and are currently being used in the developed countries. But coverage in third world countries like India (which accounts for almost 40% of the worldwide childhood pneumonia cases) is low, particularly of pneumococcal vaccines‖ said Dr Ritu Garg, senior Gynaecologist and Obstetrician, Yash Hospital, Lucknow. ―Vaccination against pneumonia should be made available in government hospitals‖ said Dr Garg as most people find it difficult to afford it and thereby their children are at a heightened risk of pneumonia. Vaccination against pneumonia is only available for children and not for adults, said Dr Nidhi Johri, senior Gynaecologist and Obstetrician, Hope Mother and Child Care Centre, Lucknow. The WHO has also recommended that exclusive breastfeeding a child for first six months, protecting the child from

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exposure to secondhand tobacco smoke or smoke coming out of cook stoves, maintaining high levels of hygiene and cleanliness, providing balanced nutritious diet to the pregnant woman and postnatal to mother and child (after 6 months, before 6 months mother‘s milk is complete nutrition for the child), and other measures will help prevent pneumonia, said Dr Johri. Vaccination against pneumonia is currently not a part of the free vaccines provided to children in government hospitals, also said Dr Johri. ―Immunization protects children from pneumonia. All children have the right to this protection. The WHO immunization schedule for infants recommends that children receive Hib and Pneumococcal conjugate vaccine (PCV) in 3 doses over a period of the first 6 months. These are not available in government public sector hospitals. In government hospitals seven vaccinations are provided which includes DPT, polio, BCG, hepatitis B among others. However if parents want their children to be vaccinated against pneumonia then they have to buy it from the private pharmacies,‖ said Dr Santosh Rai, senior Paediatrician, Vatasalya Clinic, Lucknow. ―Pneumonia vaccination can cost up to Rs 15,500. The cost of vaccination against pneumonia is clearly out of reach of many people who might have otherwise got their children protected against certain forms of pneumonia‖ said Dr Ajay Kumar, senior Paediatrician, Hope Mother and Child Care Centre, Lucknow. Dr Kumar agrees too that vaccination against pneumonia is not available in the government public healthcare service centres. However this vaccination as per the WHO guidelines is available at his clinic. Dr Ajay Kumar also said that it is not whether a child comes from a poor or rich family, rather the presence of risk factors that put a child at a greater risk of pneumonia. Even children from rich families can be malnourished or exposed to secondhand tobacco smoke for instance. Lack of health literacy and awareness on how to protect children from infections such as pneumonia are reasons why we see preventable infections in children despite efforts.

Neeraj Mainali - CNS
(Translation: CNS)

Lack of health literacy and awareness on
how to protect children from infections such as pneumonia are reasons why we see preventable infections in children despite efforts

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Lack of awareness about pneumonia vaccine
Although vaccination against certain kind of pneumonia is widely available and recommended by the World Health Organization (WHO) yet it remains out of reach of millions of children who might have benefitted by it and not developed pneumonia had they received the shot in time. The cost of the pneumonia vaccine is prohibitive and a clear barrier to access. But the low levels of awareness about pneumonia vaccination also keep the potentially life-saving shots out of reach of most at risk children. No wonder that the pneumonia vaccination is not a part of the free vaccines provided to children by the government in public healthcare centres in India. Interviewing a cross-section of healthcare providers in Bahraich and Gonda districts of Uttar Pradesh state, it is evident that information about standard pneumonia vaccination as recommended by the WHO is lacking, and at times, misleading. Although pneumonia vaccines are available in private pharmacies and available at some private sector healthcare centres (upon payment) yet most lacking is the information in the parents of the new born child who aren‘t aware that if they can afford the vaccine, their child can be protected against certain kind of pneumonia.

According to a study children who aren‘t vaccinated against pneumonia and develop pneumonia in their childhood, are 40% more likely to die of pneumonia. Also awareness is lacking most where it is needed most. Parents and caretaker guardians of children who come from poor families had the least knowledge about pneumonia vaccination. They weren‘t even clear about the vaccines that the child has received although their vaccination card in some instances clearly had it written. Low health literacy, low literacy rates, poverty, and very little health information being provided in healthcare centres are clearly some of the obstacles that prevent children from getting vaccinated against pneumonia. Pneumonia related deaths are bound to increase if vaccination continues to remain out of reach of most children. Literacy about health and pneumonia prevention, treatment and care should be scaled up so that communities are more prepared to control infections such as pneumonia and protect their children. According to a study Haemophilus influenzae type B (HiB) vaccine

The cost of the pneumonia vaccine is prohibitive and a clear barrier to access. But the low levels of awareness about pneumonia vaccination also keep the potentially life-saving shots out of reach of most at risk children

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if provided to children can potentially reduce 400,000 deaths attributed to childhood pneumonia. Apart from Haemophilus influenzae type B (HiB), the other vaccine against pneumonia is called Pneumococcal conjugate vaccine (PCV). The HiB vaccine is available in about 140 countries and PCV in over 30 countries. In India these vaccines are only available in private pharmacies and healthcare centres and not provided by the government-run national immunization programme. Dr KK Verma, senior Paediatrician, Bahraich District Hospital, said that although pneumonia vaccination is available in the market but it is very expensive and that is why most of his patients are unable to afford it or get their children vaccinated against pneumonia. Speaking with a mother who had come to Bahraich District Hospital with a 2.5 years old child suffering from pneumonia, it is clear that information and health literacy is lacking. Child‘s mother said that she did get her child vaccinated but she is not aware which vaccines her child was provided after birth. Even some healthcare providers are unclear about vaccination against pneumonia. A senior Gynaecologist and Obstetrician at Bahraich District Hospital Dr PK Mishra said that he is providing DPT vaccines to the children in his government hospital and vaccination against pneumonia is not provided here. He said he is not aware of pneumonia vaccines as well. Dr KK Verma argues that the government and the WHO must come up with vaccines that are not only effective but also affordable.

Rahul Kumar Dwivedi – CNS
(Translation: CNS)

Dr KK Verma argues that the government and the WHO must come up with vaccines that are not only effective but also affordable

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THEME 5
Access to standard quality treatment to save lives from pneumonia

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Treat Pneumonia With The Wonder Drugs
Pneumonia is a severe form of acute lower respiratory infection that specifically affects the lungs. It is the prime cause of child mortality under 5 accounting for 20% post-neonatal deaths worldwide. The best way to reduce pneumonia related mortality is to provide timely and effective treatment. When children suffering from pneumonia are promptly treated with antibiotics, popularly known as ―wonder drugs‖ chances of mortality are considerably lowered. Estimates suggest that if antibiotic treatment were universally delivered to children with pneumonia, around 600,000 lives could be saved each year. This number could more than double to 1.3 million if both prevention and treatment interventions to reduce pneumonia deaths were universally delivered. Chest X-rays and laboratory tests are used to confirm the disease in which pus and fluid fill the alveoli in one or both lungs, which interfere with oxygen absorption, making breathing difficult. But in resource-poor settings, suspected cases of pneumonia are diagnosed by their clinical symptoms like rapid or difficult breathing, cough, fever, and wheezing. Infants may be unable to feed or drink and may also experience unconsciousness, hypothermia and Estimates suggest convulsions. Caregivers, therefore, have an that if antibiotic important role to play in recognizing the symptoms of pneumonia in children and treatment were medical care. Non-severe universally delivered seeking appropriate treated with appropriate pneumonia can be antibiotics. Severe pneumonia cases should be to children with pneumonia, around referred urgently to aif hospital for injectible antibiotics and oxygen needed.

600,000 lives could be saved each year. This number could more than double to 1.3 million if both prevention and treatment interventions to reduce pneumonia deaths were universally delivered

Three essential steps needed to reduce deaths among children under five with pneumonia are (i) recognize that a child is sick with pneumonia, (ii) seek appropriate care, at hospitals/health centres/maternal and child health clinics, and (iii) get recommended treatment. However, only an estimated 20% of the care givers in developing countries recognize the symptoms and only about 54% respond to them by taking the child to a health care provider. As compared to poor children, children from urban and educated families are more likely to be taken for appropriate medical care. Also, only about 33% of the children with suspected

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pneumonia in 68 high burden countries receive antibiotics. Infants under two months with signs of pneumonia/sepsis are at greater risk of suffering severe illness and death more quickly than older children, and should be immediately referred to a hospital for treatment. Treatment regimens need to be chosen based on their efficacy in local settings. Some areas may have high levels of resistance to certain antibiotics, rendering those drugs less effective for treating pneumonia. Other areas may have large numbers of high-risk groups, such as undernourished or HIV-positive children, and may need to adapt their treatment strategies accordingly. Dr SK Sehta, Consultant Paediatrician and Neonatologist of Lucknow explains that, ―The Government of India (GOI) and the World Health Organisation (WHO) have recommended steps for easy diagnosis of pneumonia so that even in the villages, where doctors are not available, a layman can diagnose this disease. Basically the WHO has categorized three types of pneumonia: (i) No pneumonia; (ii) Pneumonia - the treatment of which is Septron and (iii) Severe Pneumonia – In this case the GOI recommends that if the person is trained he/she should administer ampicillin- gentamycin to the patient and refer the patient to a specialist.‖ Dr SN Rastogi, Paediatrician and Child Cardiologist of Lucknow says, ―Treatment depends on the causative agents which could be bacteria or even non bacteria. Thus the treatment differs. In India the most common pneumonia is tubercular pneumonia. For treating pneumonia we can give streptomycin.‖ Dr SK Sehta, who has worked for a number of years in renowned public as well as private hospitals of Lucknow and Delhi, says, ―The WHO recommendations are being followed in government hospitals. GOI and the WHO focus on the concerns of the masses. Hence Septron is a very good and cheap treatment for pneumonia and is recommended by GOI in the rural areas. However in the private sector individual concern is more important for us and we are observing high resistance to Septron. So we choose to give stronger antibiotics.‖ . According to Dr Neelam Singh, Consultant Obstetrician and Gynaecologist and Chief Functionary of Vatsalya Resource Centre on Health, acute respiratory tract infections treatment in children is a part of the Comprehensive Child Survival programme in many States. However, the kind of awareness drive that is needed for pneumonia prevention is lacking. There is still a lot of ignorance and a special drive needs to be conducted to spread awareness. Pneumonia is a major life threatening disease of children after diarrhoea. Time, advice, treatment, cost of treatment and other factors are responsible for the disparity between the treatments administered in the government and private hospitals. The government has made great progress in this field and now these treatments are available in government hospitals too. However, the pressure of large number of patients, shortage of experts, lack of infrastructure, and non availability of

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medicines are some of the concerns in the public health system that need attention. A quintessential example of how improper management of pneumonia in children can lead to severe complications comes from the story of Atharva, a 3 years old child who was recuperating in the paediatric wing of the Chattrapati Sahuji Maharaj Medical University (CSMMU and erstwhile King George‘s Medical College) when I met him in the first week of October, 2011. His parents had sought prompt medical treatment in the private sector at the first sign of pneumonia. But they ran from one nursing home to another, while the condition of Atharva deteriorated. They felt that the doctors were interested only in extracting money from them, before finally giving up on the child. As a last resort, they took him to CSMMU, a government hospital, on the 4th of August. He finally responded to some latest antibiotic available in the market and his condition stabilised. This is a classic example of how we in India, tend to generally undermine the government health system, which, despite its inherent drawbacks, is capable of providing the best of care to critically ill patients. The Global Action Plan for the prevention and control of pneumonia (GAPP) launched in 2009, aims to accelerate pneumonia control with a combination of interventions to protect, prevent, and treat pneumonia in children. Let us all join hands to ensure that every sick child has access to the right kind of care and treatment for pneumonia.

Somya Arora – CNS

His parents had sought prompt medical treatment in the private sector at the first sign of pneumonia. But they ran from one nursing home to another, while the condition of Atharva deteriorated. They felt that the doctors were interested only in extracting money from them, before finally giving up on the child. As a last resort, they took him to CSMMU, a government hospital, on the 4th of August. He finally responded to some latest antibiotic available in the market and his condition stabilised

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Antibiotic Therapy: The Pneumonia Panacea
Pneumonia is the single largest cause of death in children worldwide. It kills an estimated 1.6 million children every year – more than AIDS, malaria and tuberculosis combined. Almost four children die from pneumonia every single minute. Research has shown that prevention and proper treatment of pneumonia could avert one million deaths in children every year. With proper treatment alone, 600 000 deaths could be avoided. The World Health Organization (WHO) and UNICEF launched Integrated Management of Neonatal and Childhood Illness (IMNCI) and which aims to protect, prevent, and treat pneumonia in children. There have been few studies of the clinical efficacy for identifying and treating pneumonia in children in developing countries with low-cost, low-tech medication and care. Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which are filled with air. When an individual has pneumonia, the alveoli get filled with pus and fluid, which makes breathing painful and limits oxygen intake. The common symptoms of pneumonia are rapid or difficult breathing, cough, fever, chills, loss of appetite and wheezing in case of very severe pneumonia. When it becomes critical, children may experience in-drawing of chest, hypothermia and convulsions. Pneumonia can be treated with antibiotics, but less than 20% of children with pneumonia receive the antibiotics they need. Although the WHO guidelines advise health workers to provide oral antibiotics for cases of nonsevere pneumonia and to refer severe cases to hospitals for treatment with antibiotics by injection, many children with severe pneumonia either die before they reach a hospital, or are so sick by the time they arrive that nothing more can be done to save them. Hence, WHO, and UNICEF have initiated a Global Action Plan for Prevention and Control of Pneumonia (GAPP) in the context of child survival strategy which identifies priority activities that need to be conducted to reduce pneumonia mortality. About 60% of pneumonia cases in the developing world are caused mainly by bacteria. Antibiotics to a large extend can control pneumonia if provided well on time. Professor (Dr) YC Govil (Professor of Paediatrics in Chatrapati Shahuji Maharaj Medical University) says," Penicillin was discovered in the 1930s, and before that there were no antibiotics and people use to die like flies. Similar thing will happen if pneumonia is

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not checked. It is unfortunate, but now a days, a lot of antibiotic misuse is happening in our country and the reason is that many a times patients are been treated by unqualified practitioners of medicine in rural areas. I think almost 20%-30% or even more of patients would initially go to an unqualified practitioner. So here they are in the habit of advising lots of broad spectrum antibiotics in the beginning. Even in viral infection, where antibiotics are not usually indicated, antibiotics are prescribed. This is also prevalent in the urban setup as well. Very often patients try to self medicate also, as antibiotics are easily available over the counter. This develops a resistance against normal (narrow spectrum) antibiotics, thus making them ineffective." Very severe pneumonia in children under five requires treatment with injectible antibiotics in a hospital. The case management strategy for very severe pneumonia, which includes treatment with injectible chloramphenicol followed by oral chloramphenicol, has successfully decreased child deaths from pneumonia. WHO recommends the treatment at the level of primary health workers, and for them the guidelines are just to recognize it by increased respiratory rate and administer some basic antibiotics and if required then refer the child to a hospital. Dr Vijaya Mohan (Consultant Pediatrician, Vivekananda Polyclinic and Institute of Medical Sciences) says," We can diagnose pneumonia by physical and clinical findings and also by examining blood or X-ray. Even if the facilities are not available then by simply examining the child one can detect pneumonia. Antibiotics administered in the treatment of pneumonia, actually depend on the organism which is causing pneumonia. Penicillins, cephalosporins are usually suggested. But in the field WHO recommends Cotrimoxazole, Chloramphenicol." Hence the role of antibiotics becomes imperative, and the probability of treating pneumonia through their use becomes quiet broad. They are usually prescribed at health centers or hospitals, but the vast majority of cases of childhood pneumonia can be administered effectively within the home. Hospitalization is recommended in infants aged two months and younger, and also in very severe cases. WHO rightly believes that a large number of deaths in children could be prevented or treated with access to simple and affordable medicines. These are available even in the government health care centres. Still the deaths due to pneumonia are very high due to a host of reasons. Delay in diagnosis and access to proper medical services are major road blocks. According to Prof Govil, ―Awareness and correct implementations are the definite interventions against pneumonia. Not only the government, but also the masses are required to take strict measures against it. Treat well to get well should be the motto. ―

Shikha Srivastava - CNS

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Treat childhood pneumonia before it gets too late
Pneumonia is the leading single cause of childhood mortality. Childhood pneumonia accounts for 19 per cent deaths in children less than 5 years. Pneumonia kills more children than any other illness, more than measles, malaria and AIDS combined. According to the World Health Organization (WHO) globally 156 million new pneumonia cases are reported every year in the developing world. As many as 8.7 per cent of these cases are severe enough to be life-threatening and require hospitalization. India accounts for the maximum 43 million new cases followed by China (21 million cases) and Pakistan (10 million cases). Pneumonia is estimated to kill 410,000 children in India every year. Haemophilus influenza and Streptococcus pneumonia are the main causes of bacterial pneumonia and estimated to be the causative organisms for more than 50% of all childhood pneumonias. In addition some diseases, like measles and pertussis (whooping cough) can lead to pneumonia as a complication. It has been shown through various studies that mortality due to pneumonias could be decreased by interventions like prevention of pneumonia through immunization, early diagnosis and optimal case management, exclusive breastfeeding for six months, reducing indoor air pollution, preventive antibiotic treatment in HIV infected children and zinc supplementation. In India, pneumonia is responsible for an estimated 410,000 deaths in children under five and a substantial proportion of these deaths are due to pneumococcal pneumonia. While treatment with antibiotics reduces mortality, lack of access to care and delay in provision of antibiotics, especially among the poor and most vulnerable children result in high case fatality from pneumonia. Studies have shown that up to 19% of children hospitalized with pneumonia die in India.

DRUG RESISTANCE
Another consideration is the rising resistance to commonly used antibiotics worldwide associated with increasing rates of treatment failures. Hence, prevention of Pneumonia through immunization is an effective way to decrease the incidence and prevent mortality and morbidity in children. Among immunizations, introduction of Haemophilus influenza (Hib) and

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Pneumococcal vaccines (PCV) and improving immunization coverage of Measles and Pertussis vaccine have been shown to decrease the incidence of Pneumonia in children under 5 years of age. Hib and Pneumococcal vaccines are safe and cost-effective vaccines and are instrumental in preventing serious and fatal pneumonia in young children under 5 years of age. The WHO recommends prioritizing the use of vaccines, as millions of children, specially the poor, remain at high risk of dying from pneumonia. Introduction of Hib and Pneumococcal conjugate vaccines into the childhood immunization programmes, especially in developing countries, will contribute effectively to achieving the Millennium Development Goal of globally reducing childhood deaths by two-thirds by 2015. Regarding the cost of Hib and Pneumococcal vaccines, it is recognized that the price in the private market and in industrialized countries is relatively high at present, but past experience, for example with the hepatitis B vaccines, shows that the cost of vaccines do decline drastically when introduced on a large scale. At the projected public sector prices in developing countries, these vaccines are considered highly cost-effective and a worthy allocation even if a country were to self-finance the procurement of the vaccine. The above pattern of ultimate reduction in vaccine cost is also true for the cost of life-saving treatments such as for AIDS, and which have substantially declined over time.

Rahul Kumar Dwivedi – CNS
(Translation: CNS)

Regarding the cost of Hib and Pneumococcal vaccines, it is recognized that the price in the private market and in industrialized countries is relatively high at present, but past experience, for example with the hepatitis B vaccines, shows that the cost of vaccines do decline drastically when introduced on a large scale

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Barriers to accessing treatment for childhood pneumonia
Despite making compelling public health sense to integrate pneumonia prevention, treatment and care services in public sector healthcare facilities as childhood pneumonia is a leading cause of mortality for children below 5 years of age, the reality remains grim. Not only healthcare services in public sector lack quality standard prevention and treatment services but also there is a lack of guidelines so that pneumonia related services can be uniform in private and public healthcare services. For example, effective pneumonia vaccines are not included in the government-run immunization programme and not provided free in the public sector healthcare facilities. However in private-sector healthcare facilities in some instances high quality pneumonia prevention, treatment and care services are provided at a very high cost which is clearly unaffordable for majority of children who come from poor families and paradoxically are likely to be at higher risk of pneumonia (and least likely to access existing pneumonia services). In public sector healthcare facilities, pneumonia treatment is available and in some instances competence of paediatricians and other attending healthcare workers is unparalleled. However in Gorakhpur and other smaller towns and nearby villages, the reality check presents an appalling picture. Said a nurse in a government hospital in Gorakhpur: "Children with pneumonia reach this hospital so late because of poor awareness, lack of resources to go to a city hospital or other reasons. On the first instance usually people either self-treat pneumonia or go to their local pharmacy or doctor. By the time they reach us the child is mostly in a serious condition." Said Indravati, a slum resident: "Although my grandson got treatment for pneumonia in government hospital but we went only when there was no response in his condition at the local clinic. Also the cost of going to the hospital which is about 15 km away, leaving our daily labour work, missing out on our daily wage, and attending to the child in the hospital is prohibitive and makes it very difficult for us to access such services upon first instance of symptoms. Usually when nothing else is working we go to the big government hospital. Why else will we go there?"

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She is right. Why are healthcare workers in local primary healthcare centre not well equipped to treat pneumonia? Why is pneumonia vaccination not being provided in the national immunization programme run by the Government of India? Why is pneumonia which is preventable and curable allowed to become the single largest cause of childhood mortality for children below the age of 5 years? Let us hope that the government's Planning Commission that is currently preparing the 12th Five Year Plan (2012-2017) reviews the immunization programme and integrates pneumonia vaccination as well.

Jitendra Dwivedi – CNS
(Translation: CNS)

Let us hope that the government's Planning Commission that is currently preparing the 12th Five Year Plan (2012-2017) reviews the immunization programme and integrates pneumonia vaccination as well.

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Childhood pneumonia: a public health challenge
Despite being the single largest cause of deaths of children below the age of 5 years, responses from the government of India‘s health programmes to protect children from childhood pneumonia and diagnose early those who develop pneumonia and treat them, is far from satisfactory. Pneumonia vaccination is not included in the national immunization programme rolled out by the government of India through public healthcare services. Treatment guidelines are unclear to healthcare providers in India who come from a broad range of medical disciplines and unclear linkages of health programmes with those development programmes that reduce the risks for a child to develop pneumonia, such as tobacco control, housing, nutrition, environment or pollution control, among others, are key barriers. Pneumonia vaccination is not available free of cost in the government hospitals as it is not a part of government‘s free immunization programme, said Dr Santosh Rai, senior Paediatrician, Vatsalya Clinic, Lucknow, when we asked him about availability of the World Health Organization (WHO) recommended vaccination to prevent children from pneumonia. There is a difference between healthcare services in private and public sector. The WHO guidelines classify pneumonia into three kinds: mild, moderate or severe. On a general note childhood pneumonia continues to remain a formidable challenge in rural India compared to urban parts. Agree Dr Ajay Kumar, senior Paediatrician, Hope Mother and Child Care Centre, Lucknow: Pneumonia vaccination is not available in government hospitals however it is available in private healthcare services, such as the Hope Mother and Child Care Centre. Because vaccination against childhood pneumonia is very expensive it is beyond the reach of many people who want their children to be vaccinated but aren‘t able to afford it. There is not much difference in treatment of childhood pneumonia in government or private healthcare service centres however he points out the quality of service in government hospitals that force people to turn towards private healthcare service providers and shell out lot of money. In most private hospitals and government healthcare centres that deal with paediatric cases

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managing childhood pneumonia as per the WHO guidelines is possible, said Dr Kumar. There is a difference between treatment services in private and government healthcare centres, said Dr Nidhi Johri, senior Gynaecologist and Obstetrician, Hope Mother and Child Care Centre, Lucknow. In private hospitals treating doctors take full responsibility of the clinical management of their cases and this increases accountability, but in government hospitals it is the ‗umbrella treatment‘ approach where different experts are available on different days or timings. In the rural parts of India pneumonia management as per the WHO guidelines might not be available but in most urban areas childhood pneumonia is managed as per the WHO guidelines, said Dr Johri. At times, in government hospitals children with pneumonia are barely given antibiotic or bronchodilator injections which is not enough to manage childhood pneumonia, said Dr Ritu Garg, senior Gynaecologist and Obstetrician, Yash Hospital, Lucknow. Very few government hospitals adhere to the WHO guidelines for treatment of childhood pneumonia. Yash Hospital, a private healthcare centre, manages childhood pneumonia as per the WHO guidelines too. Dr Garg points out another challenge in management of childhood pneumonia – diagnosing pneumonia correctly. She said: children often presents with symptoms that are common to three similar conditions, pneumonia being one of them. The other two conditions are: bronchitis (where inflammation of lungs takes place in children which causes light cough) and broncho-pneumonia. Children with broncho-asthma or asthma also presents with similar symptoms said Dr Garg and treating doctors should be competent to diagnose pneumonia or other conditions a child may be suffering from correctly. The WHO recommended treatment and care services for pneumonia should be available for all children who need it regardless whether they can afford it or not.

Neeraj Mainali – CNS
(Translation: CNS)

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Childhood pneumonia is curable
Pneumonia is one of the most common infections in children who aren‘t breastfed, are exposed to indoor air pollution, are malnourished or live in over-crowded or polluted surroundings. Pneumonia can be transmitted via bacteria, virus, among other pathogens. However the good news is that pneumonia is preventable and if it does occur then it is curable with standard treatment at the right time. ―We should protect children from getting exposed to people who have any bacterial or viral infections, or are coughing, smoking or from exposure to any smoke such as that coming out of cook stoves, or from exposure to cold weather. The children should not be exposed to those family members, visitors or other people who are coughing. Children should also receive timely vaccination. According to the World Health Organization (WHO), we provide septran, ampicilin and antamicin to treat pneumonia. Apart from these other medicines are also given the pneumonia affected child depending upon her or his medical condition. For example when there is breathing problem then the child is also put on oxygen. In our hospital which is a government hospital, all standard facilities for management of childhood pneumonia are available‖ said Dr Abhishek Verma, senior Paediatrician, Dr Ram Manohar Lohia Hospital, Gomti Nagar, Lucknow. ―The government is very attentive towards mother and child care, and there are number of interventions to address their health issues such as „Janani Suraksha Yojna.‟ Pneumonia management is done as per the guidelines of the WHO in our hospital‖ said Dr RS Dubey, Chief Medical Superintendent (CMS), Dr Ram Manohar Lohia Hospital. Treating pneumonia early on has great benefits. ―When a child suspected with pneumonia comes to my clinic we immediately refer it to paediatrician for treatment. The earlier a child is treated for pneumonia the greater the chances are of cure and lesser the chance of serious complications‖ said Dr Rama Shankhdhar, senior Gynaecologist and Obstetrician, Rama Consultations and Training Centre, C-block crossing, Indira Nagar, Lucknow. Added Dr Shankhdhar: ―At times there are drug stock-outs in government hospitals. Also government hospitals will provide medicines that are available in their stock. In private sector hospitals options for treatment of

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pneumonia or other conditions are not limited to few drugs rather what is best and appropriate for the patient is prescribed. We also follow the guidelines of WHO for management of pneumonia.‖ Children below the age of 5 years are at a heightened risk of pneumonia. There are simple and practical modifications in our daily lives that can considerably reduce the risk of childhood pneumonia, such as, keeping the child warm and dry, away from those with infections such as cold or cough, not exposing the child to smoke (tobacco smoke, smoke from cook stoves), breastfeeding (exclusive) the child for first six months, among others. Children should be taken to healthcare services on the first symptom such as fever or cold. If the child is not breastfeeding then instead of giving her or him other home-made food please consult a doctor without delay. If the healthcare provider is recommending hospitalization for the child then don‘t avoid it unless indicated otherwise. Maintaining strict hygiene and cleanliness is also important for child care and preventing pneumonia and other infections.

Nadeem Salmani – CNS
(Translation: CNS)

Children should be taken to healthcare services on the first symptom such as fever or cold. If the child is not breastfeeding then instead of giving her or him other homemade food please consult a doctor without delay. If the healthcare provider is recommending hospitalization for the child then don‘t avoid it unless indicated otherwise. Maintaining strict hygiene and cleanliness is also important for child care and preventing pneumonia and other infections.

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ATHARVA: Tell-tale of a pneumonia crusader
15 OCTOBER 2011: Atharva, is a 2 years and 10 months old child who is battling for life at the Paediatric Intensive Care Unit (ICU), Chhatrapati Shahuji Maharaj Medical University. Hospitalized for over 3 months the child gets terrified even at the sight of equipments. He tried to hide in his mother‘s lap seeing the CNS reporter‘s camera and other gadgets. Atharva‘s father is a PAC jawan. His mother Mrs. Renu Bala Sharma had a long painful story to tell. ―He got fever on the 21st July. We consulted a private doctor in Sujanpura, Alambagh regularly for 3 days that is 22nd, 23rd and 24th July 2011. On the 25th July, he told us that our child has pneumonia.‖ When enquired about whether she had heard about the disease earlier she says, ―We had heard that pneumonia is a common disease of children and children do get infected with it often but we had never thought it would get so serious.‖ Atharva‘s parents are well-educated and showed no negligence towards their child‘s illness. They consulted medical help as soon as Atharva got fever and chest congestion. His mother adds, ―He had no disease before. The first day he got fever we brought him to the doctor. We can‘t be careless with our child. We had sought medical attention immediately.‖ From here began a series of hospitalizations. Mrs. Sharma says, ―So we took him to another private children‘s hospital in L.D.A. Colony and got him admitted there. He was treated there till 29th July. On the 29th July they told us that the bag of pneumonia has burst inside. There is a bag inside. Suddenly it appeared that he is not being able to breathe. We felt it is his last hour and it seemed very difficult that we would be able to reach a super-speciality mother and child Hospital in Alambagh (popular for IVF) in time. They said that if we can spend money then we can refer him to this hospital. We said that that money is not important we want our child. So he was brought to this hospital on 29th July and got him admitted around 4pm.‖

―He had no disease before. The first day he got fever we brought him to the doctor. We can’t be careless with our child. We had sought medical attention immediately‖
- Atharva‟s mother

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Private hospitals mostly operate with the aid of on-call doctors who are called when a patient of their specialization is admitted. There is no 24 hour supervision of experts. In a serious illness as pneumonia where the patient‘s condition deteriorates quickly, such an arrangement can put several lives at risk and it did in Atharva‘s case as well. At this super-speciality mother and child hospital, Alambagh, Atharva‘s condition worsened until he was put on ventilator and taking probably his last breaths as the doctors there had declared so.

Private hospitals play very safe when admitting cases. A complicated case with meagre hope of survival is rejected to save the private hospital‘s brand name. Athatva‘s parents even tried to approach the city‘s biggest multispeciality hospitals for help. Mrs. Sharma says, “We tried to approach Lucknow‟s new and biggest multispeciality hospital in Gomti Nagar but they denied accepting such a severe case.”

Atharva‘s mother laments, ―There they saw two X-rays which were of the initial stages. When they examined him they said that it has got filled with air. The pneumonia has burst, I‘m expressing in my language from my understanding. They inserted I.C.D. after which he was relieved a little. It appeared that now he is able to breathe. Then they asked us to bring blood bottles for transfusion. We came to the medical college to get blood. The blood was given in three stages. They kept on giving their treatment. They did not tell us anything and carried on with their treatment. We felt very helpless. All we could do was shell out money and watch the doctors with hope. The condition of my child kept on deteriorating. They had inserted a single tube and following that another thick tube, which caused his body to swell tremendously. My two year old son appeared to be ten years old. His cheeks had swollen. It felt as if his eyes would fall off. It seemed as if air had filled up in his entire body. He would lie down and they would make incisions, then force out the fluids by applying pressure. His genital region had also swollen up. The doctors would do nothing despite our request. They would say we can take the child anywhere we wanted to. In the end they put him on ventilator. They told my husband that now he has only two hours of life left. Your child will survive for hardly 2 hours.‖ For a middle-class family private hospital treatment can mean a life time‘s saving, but Atharva was lucky to find help of some relatives. Mrs. Sharma narrates, ―At that time all my family members, my sister, sister‘s husband, 102 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

brother, brother‘s wife everybody had gathered there. They all were trying to find a way to save my child‘s life. We have spent about INR 150,000 in his treatment already. I only want my child healthy and sound now.‖ Private hospitals play very safe when admitting cases. A complicated case with meagre hope of survival is rejected to save the private hospital‘s brand name. Athatva‘s parents even tried to approach the city‘s biggest multispeciality hospitals for help. Mrs. Sharma says, ―We tried to approach Lucknow‘s new and biggest multispeciality hospital in Gomti Nagar but they denied accepting such a severe case.‖ Finally Atharva was brought to the government-run tertiary care centre and medical college, Chhatrapati Shahuji Maharaj Medical University (CSMMU) – erstwhile King George‘s Medical College - on 5th August 2011. His mother takes a sigh of relief saying, ―They did not leave any treatment. It was his destiny and our good luck that he survived. At one point we were at dead end. I felt my child won‘t come back to me. Professor (Dr) YC Govil is like a God for me.‖ Futher narrating the apathies of private hospitals she adds, ―We feel that his condition got so complicated only because of negligence on the part of doctors. They did not get any tests done. They did not know what treatment to give. They were treating him on guesswork. They were even giving treatment for TUBERCULOSIS, the tablet which is given empty stomach in the morning.‖ Atharva was a healthy child but wasn’t exclusively breastfed for the first six months, probably due to lack of awareness about its importance in preventing pneumonia and other childhood illnesses. His mother says, ―I have breastfed my child. Even now he wants me to feed him but because we are in a hospital I don‘t want to feed him. During the first five months I used to give apple juice and water along with my milk but I started giving him cereals only after his „Annaprashan‟ at the start of his sixth month. He used to eat everything. Gradually he had started taking everything.‖ The pneumonia vaccination because of its high cost has not yet been included in the Government of India‘s vaccination programme. There is also little awareness among the masses about the existence of these vaccines and about the fatal nature of the disease. Atharva‘s parents are no different. His mother laments, ―We got him vaccinated against every disease. At the one and a half month then at two and a half months. There is a immunization card. We went by the card. We 103 | V o i c e s f r o m t h e f i e l d o n c h i l d h o o d p n e u m o n i a

don‘t know whether it had pneumonia vaccine also in it. We have spent lakhs of rupees already on his treatment. Had we known about the vaccine we would have definitely got him immunized.‖ Development of antibiotic resistance among common pathogens is a global concern. Professor (Dr) YC Govil, Department of Paediatrics, CSMMU, remarks ―There is a lot of disparity in between the treatment at private and government hospitals. Lot of antibiotic misuse is happening in our country and the reason is many a times patients are been treated by unqualified practitioners of medicine in rural areas. I think almost 20-30% of patients would initially go to an unqualified practitioner. So here they are in habit of advising lots of broad spectrum antibiotics in the beginning. Even in viral infection where antibiotics are not usually indicated. This is also prevalent in the urban setup as well. Before the first wonder drug penicillin was discovered men used to die like flies and if this trend continues that era would return.‖ The senior resident doctor incharge of Atharva told the CNS reporter that Atharva was on ventilator when brought. Further he adds, ―His sputum showed positive result for multiple pathogens like Streptococcus pneumonia and Eshcherichia coli. He did not respond to any of the traditional antibiotics. Finally was given tigecycline, a newly released and most advanced chemotherapeutic agent. The patient responded to it and was removed from ventilator. The patient is stable now. But under observation.‖

Somya Arora - CNS

―There is a lot of disparity in between the treatment at private and government hospitals. Lot of antibiotic misuse is happening in our country and the reason is many a times patients are been treated by unqualified practitioners of medicine in rural areas. I think almost 20-30% of patients would initially go to an unqualified practitioner. So here they are in habit of advising lots of broad spectrum antibiotics in the beginning. Even in viral infection where antibiotics are not usually indicated. This is also prevalent in the urban setup as well. Before the first wonder drug penicillin was discovered men used to die like flies and if this trend continues that era would return‖
Professor (Dr) YC Govil, Department of Paediatrics, CSMMU

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About the CNS authors
SOMYA ARORA
Somya is currently doing her post-graduation from Lucknow University in microbiology and writes on social justice issues for CNS. Recently her article on significance of breastfeeding was published in The Hindustan Times.

SHIKHA SRIVASTAVA
Shikha is also doing her post-graduation from Lucknow University in microbiology and writes on social justice issues for CNS.

SHOBHA SHUKLA
Shobha is the Managing Editor of CNS: www.citizen-news.org She is a J2J Fellow of National Press Foundation, USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent for three decades.

NEERAJ MAINALI
Neeraj is a philanthropist based in Lucknow and has written extensively on a range of social justice issues and got published over the past years. He writes for CNS as well. RAHUL KUMAR DWIVEDI Rahul leads the News Monitoring Initiative of CNS and has written on health and development issues. He has also been awarded the Youth Scholar Award at the 15th WCTOH, Singapore, 2012. NADEEM SALMANI Nadeem had earlier worked with ETV and is presently part of the News Monitoring Initiative of CNS. He writes in Hindi and Urdu languages as well. RITESH ARYA Ritesh is part of the News Monitoring Initiative of CNS and has demonstrated considerable commitment to health issues over the past decade. JITENDRA DWIVEDI Jitendra currently works with the Gorakhpur Environment Action Group and has written consistently on agriculture and gender issues getting published in national publications. JITTIMA JANTANAMALAKA Jay is a senior radio programme producer and leads CNS Thailand BOBBY RAMAKANT Bobby writes extensively on health and development for CNS and received the World Health Organization (WHO)‘s Director-General‘s WNTD Award (2008)

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Gift your child health and wellness, and ensure:
 Child is exclusively breastfed during first six months of her/ his life  Is not exposed to smoke such as secondhand tobacco smoke or biomass smoke or pollution of any kind (dust, etc)  Care-providers including the mother maintains high standards of personal hygiene and cleanliness while caring for the child (handwashing, etc)  Pregnant woman and postnatal mother and child are particularly well-fed on nutritious and balanced diet (for first six months of the child‘s life, mother‘s milk is the complete and best food)  Children receive proper vaccination including that of pneumonia if possible  Recognise signs of illness early in children and seek medical attention without delay

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