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ANM / Multi-Purpose Health Assistant (Female) · Chapter 6

Child Health and Immunisation

What to remember

  • Immunisation is the most cost-effective way to protect a child. Know the vaccine, age, dose, route and site in the national schedule, and the cold chain rules (check the latest official schedule for any change).
  • The first 28 days, the first 1,000 days and the first 5 years decide a child's survival and growth. Early breastfeeding, warmth, clean cord care and growth monitoring are key actions.
  • Common killers are diarrhoea, pneumonia, low birth weight and malnutrition. Simple actions by the health worker (ORS, zinc, timely referral) save lives.

Newborn care and breastfeeding

The neonatal period is the first 28 days of life. A baby is term if born at 37 to 42 completed weeks, preterm if before 37 weeks. Low birth weight is a birth weight below 2.5 kg. A normal newborn weighs about 3 kg and is about 50 cm long.

Immediate care: dry the baby and keep it warm, keep skin-to-skin with the mother, clear the airway if needed, clamp and cut the cord with a sterile instrument, and start breastfeeding within one hour. Apgar score is checked at 1 and 5 minutes: it scores heart rate, breathing effort, muscle tone, reflex response and colour, each 0 to 2, for a maximum of 10. A score of 7 to 10 is normal; 4 to 6 needs help; 0 to 3 is severe depression.

Cord care: keep the stump clean and dry. Do not apply anything unless advised. Kangaroo mother care (KMC) means skin-to-skin contact on the mother's chest, with feeding on demand; it is best for low birth weight babies. Keep the room warm and avoid bathing a small baby in the first 24 hours (as per newborn guidelines). Newborn danger signs: not feeding well, fever or cold body, fast breathing, chest indrawing, convulsions, yellow palms and soles, pus from the cord and unusually sleepy. These need urgent referral.

Breastfeeding. Breast milk is the best food. Colostrum, the first yellowish milk, is rich in protein and antibodies (IgA) and is called the baby's first vaccine. Give exclusive breastfeeding for the first 6 months, with no water, honey or animal milk. Continue breastfeeding up to 2 years or more. Correct positioning and attachment prevent sore nipples. Complementary feeding starts at 6 months with soft mashed home foods, given 2 to 3 times a day at 6 to 8 months and increased later, with clean hands and clean utensils. Avoid bottle feeding because of the risk of infection.

Growth and development

Birth weight doubles by about 5 months and triples by 1 year. Growth is checked on the growth chart by plotting weight against age every month. A flat or falling line is a warning sign.

MilestoneUsual age
Social smileAbout 2 months
Holds the head steadyAbout 3 months
Rolls over4 to 6 months
Sits with supportAbout 6 months
Sits without support8 to 9 months
Stands with support9 to 10 months
Walks alone12 to 15 months
Speaks a few wordsAbout 12 months
Runs, uses two-word sentencesAbout 2 years

Delay beyond these ages needs assessment. Play, talk and affection are needed for development. The Rashtriya Bal Swasthya Karyakram (RBSK) screens children from birth to 18 years for the 4 Ds: defects at birth, diseases, deficiencies and developmental delays.

Mortality terms (formulas)

  • Infant mortality rate (IMR) = (Deaths under 1 year ÷ Live births in the same year) × 1000.
  • Neonatal mortality rate = (Deaths in the first 28 days ÷ Live births) × 1000.
  • Under-5 mortality rate is deaths before the fifth birthday per 1000 live births.

Worked example: 40 infant deaths among 2,000 live births gives IMR = 40 ÷ 2000 × 1000 = 20 per 1000.

National immunisation schedule (Universal Immunisation Programme)

Follow the latest official schedule issued by the Ministry of Health.

AgeVaccines
At birthBCG, hepatitis B birth dose, OPV-0
6 weeksOPV-1, pentavalent-1, rotavirus-1, fIPV-1, PCV-1
10 weeksOPV-2, pentavalent-2, rotavirus-2
14 weeksOPV-3, pentavalent-3, rotavirus-3, fIPV-2, PCV-2
9 to 12 monthsMeasles-rubella (MR) 1, PCV booster, vitamin A (first dose); JE-1 in endemic areas
16 to 24 monthsMR-2, DPT booster 1, OPV booster, JE-2 in endemic areas
5 to 6 yearsDPT booster 2
10 and 16 yearsTd
Pregnant womanTd-1 early; Td-2 after 4 weeks; Td booster if given in a pregnancy within the last 3 years

Pentavalent protects against diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type b. Fractional IPV (fIPV) is an inactivated polio vaccine given in small dose into the skin.

Doses, routes and sites (standard)

VaccineDoseRoute and site
BCG0.05 mL up to 1 month; 0.1 mL afterIntradermal, left upper arm
OPV2 dropsOral
Rotavirus5 dropsOral
Pentavalent, DPT0.5 mLIntramuscular, anterolateral mid-thigh
Measles-rubella0.5 mLSubcutaneous, right upper arm
fIPV0.1 mLIntradermal, right upper arm
Td0.5 mLIntramuscular, upper arm
Vitamin A1 lakh IU at 9 months; 2 lakh IU every 6 months up to 5 yearsOral

BCG leaves a small scar. Reconstituted BCG and measles-rubella vaccine must be used within 4 hours and kept in the vaccine carrier with a cold pack. A child with a mild fever, cough, cold or diarrhoea can still be vaccinated. A severe allergic reaction to a previous dose is a true contraindication. Record every dose on the immunisation card and the mother and child protection card.

Cold chain and vaccine handling

The cold chain keeps vaccines at the right temperature from the maker to the child. The ice-lined refrigerator (ILR) keeps vaccines at +2°C to +8°C. OPV can be kept in the freezer (−15°C to −25°C) at a main store but is kept at +2°C to +8°C at the health sub-centre. A vaccine vial monitor (VVM) on the label shows heat exposure; if the inner square is the same colour as or darker than the outer circle, discard the vial. Freeze-sensitive vaccines are hepatitis B, DPT, pentavalent, Td, IPV and PCV; the shake test checks if they have frozen. Heat-sensitive vaccines include OPV, BCG and measles-rubella. Diluent must be cooled to the same temperature before use. Keep a temperature chart and never store vaccines in the door of the refrigerator. Used vials and syringes are disposed of safely using the bio-medical waste rules. Auto-disable syringes are used to prevent reuse.

Adverse events following immunisation (AEFI) are minor (fever, pain, swelling) or serious (anaphylaxis, convulsions). Tell the mother about expected effects, keep adrenaline ready at the session site, and report serious events. Mission Indradhanush and the intensified drives aim to reach children missed or partly vaccinated. A "fully immunised child" has all the vaccines in the first year.

Common childhood illnesses

Diarrhoea. Danger of dehydration. Give extra fluids and ORS, continue feeding, and give zinc for 14 days (10 mg per day under 6 months and 20 mg per day for older children). Refer if there is blood in the stool, sunken eyes, drinking poorly, lethargy or high fever. Signs of dehydration: sunken eyes, dry mouth, poor skin pinch (goes back slowly), thirst.

Acute respiratory infection (ARI) and pneumonia. Danger signs are fast breathing and chest indrawing. Fast breathing means 60 or more per minute under 2 months, 50 or more at 2 to 12 months, and 40 or more at 1 to 5 years. Count for one full minute when the child is calm. Treat with an antibiotic as per the protocol and refer severe cases.

Others: measles (rash, red eyes; give vitamin A), malnutrition, worm infection (deworming with albendazole), anaemia and fever. The IMNCI strategy (Integrated Management of Neonatal and Childhood Illness) classifies illness by colour: pink (urgent referral), yellow (treat at home or facility) and green (home care and advice). Home-based newborn care (HBNC) visits by ASHA workers happen on set days in the first six weeks. Janani Shishu Suraksha Karyakram gives free delivery, drugs, diet and transport for mother and sick newborn in government facilities.

Exam traps

  • Neonatal period is 28 days; infancy is one year.
  • Low birth weight is below 2.5 kg.
  • BCG is intradermal; MR is subcutaneous; pentavalent is intramuscular.
  • Pentavalent has five components, including hepatitis B and Hib.
  • Reconstituted BCG and measles-rubella vaccines are used within 4 hours.
  • OPV is given as drops; rotavirus is also oral.
  • Freeze-sensitive: hepatitis B, DPT, pentavalent, Td. Heat-sensitive: OPV, BCG, measles-rubella.
  • Exclusive breastfeeding is 6 months, not 4.
  • Fast breathing cut-off falls with age (60, 50, 40).
  • Mild fever is not a reason to withhold vaccines.

One-liners

  • 1. Colostrum is the first milk and is rich in antibodies.
  • 2. Exclusive breastfeeding lasts 6 months.
  • 3. Cold chain temperature is +2°C to +8°C.
  • 4. ORS is mixed in one litre of clean water.
  • 5. Zinc in diarrhoea is given for 14 days.
  • 6. Apgar score maximum is 10.
  • 7. Birth weight triples by one year.
  • 8. BCG protects against severe forms of tuberculosis in children.
  • 9. RBSK covers the 4 Ds.
  • 10. Td is given to pregnant women.
  • 11. Vitamin A is given from 9 months.
  • 12. KMC is skin-to-skin care for small babies.

Practice questions

  1. The neonatal period is the first

    1. 3 months of life
    2. 7 days of life
    3. 1 year of life
    4. 28 days of life
    Answer

    D. 28 days of life

    Neonatal period covers birth to 28 days.

  2. A baby is low birth weight if birth weight is below

    1. 3.0 kg
    2. 2.5 kg
    3. 1.5 kg
    4. 3.5 kg
    Answer

    B. 2.5 kg

    WHO defines low birth weight as below 2.5 kg.

  3. Breastfeeding should be started within

    1. 3 days of birth
    2. One hour of birth
    3. 24 hours of birth
    4. 6 hours of birth
    Answer

    B. One hour of birth

    Early initiation within one hour is advised.

  4. Exclusive breastfeeding is recommended for the first

    1. 4 months
    2. 2 months
    3. 12 months
    4. 6 months
    Answer

    D. 6 months

    No water or other food for 6 months.

  5. The first yellowish milk after delivery is called

    1. Hindmilk
    2. Foremilk
    3. Colostrum
    4. Skim milk
    Answer

    C. Colostrum

    Colostrum is rich in antibodies and protein.

  6. The BCG vaccine is given by which route?

    1. Oral
    2. Intramuscular
    3. Intradermal
    4. Subcutaneous
    Answer

    C. Intradermal

    BCG is given into the skin of the left upper arm.

  7. The measles-rubella vaccine is given by which route?

    1. Intravenous
    2. Subcutaneous
    3. Oral
    4. Intradermal
    Answer

    B. Subcutaneous

    MR is given subcutaneously on the right upper arm.

  8. The pentavalent vaccine is injected into the

    1. Left upper arm
    2. Abdomen
    3. Right buttock
    4. Anterolateral mid-thigh
    Answer

    D. Anterolateral mid-thigh

    Infants get intramuscular injections in the thigh.

  9. The correct dose of OPV is

    1. 1 mL
    2. 0.5 mL injection
    3. 2 drops
    4. 5 drops
    Answer

    C. 2 drops

    OPV is given as 2 drops by mouth.

  10. The correct dose of rotavirus vaccine under the national schedule is

    1. 0.1 mL
    2. 5 drops
    3. 2 drops
    4. 1 mL
    Answer

    B. 5 drops

    Rotavirus vaccine is oral, 5 drops.

  11. Pentavalent vaccine does NOT protect against

    1. Diphtheria
    2. Haemophilus influenzae type b
    3. Hepatitis B
    4. Measles
    Answer

    D. Measles

    It covers DPT, hepatitis B and Hib.

  12. Ice-lined refrigerators keep vaccines at

    1. +15°C to +25°C
    2. 0°C to −5°C
    3. −20°C to −25°C
    4. +2°C to +8°C
    Answer

    D. +2°C to +8°C

    Standard cold chain temperature is 2 to 8°C.

  13. Reconstituted BCG vaccine should be used within

    1. 4 hours
    2. 8 days
    3. 24 hours
    4. 1 week
    Answer

    A. 4 hours

    Discard after 4 hours or at the end of the session.

  14. Which vaccine is freeze-sensitive?

    1. Measles-rubella
    2. Hepatitis B
    3. BCG
    4. Oral polio
    Answer

    B. Hepatitis B

    Hepatitis B, DPT, pentavalent and Td lose potency when frozen.

  15. The shake test is used to check whether a vaccine has been

    1. Contaminated
    2. Expired
    3. Frozen
    4. Overheated
    Answer

    C. Frozen

    A frozen and thawed adsorbed vaccine settles faster.

  16. Vitamin A is first given at

    1. 5 years
    2. 9 months with measles-rubella
    3. Birth
    4. 6 weeks
    Answer

    B. 9 months with measles-rubella

    First dose of 1 lakh IU is given at 9 months.

  17. Td vaccine is given to children at

    1. 9 months
    2. 2 years
    3. 6 weeks
    4. 10 and 16 years
    Answer

    D. 10 and 16 years

    Td replaced TT at 10 and 16 years.

  18. Fast breathing in an infant aged 2 to 12 months is

    1. 30 per minute
    2. 60 per minute only
    3. 40 per minute only
    4. 50 breaths per minute or more
    Answer

    D. 50 breaths per minute or more

    Cut-offs are 60, 50 and 40 for the three age bands.

  19. Fast breathing in a child aged 1 to 5 years is

    1. 40 or more per minute
    2. 30 or more per minute
    3. 50 or more per minute
    4. 60 or more per minute
    Answer

    A. 40 or more per minute

    Cut-off is 40 for 1 to 5 years.

  20. In diarrhoea, zinc is given for

    1. 3 days
    2. 30 days
    3. 14 days
    4. 5 days
    Answer

    C. 14 days

    Zinc for 14 days reduces repeat episodes.

  21. If there are 40 infant deaths among 2,000 live births gives an infant mortality rate of

    1. 40 per 1000
    2. 20 per 1000
    3. 80 per 1000
    4. 2 per 1000
    Answer

    B. 20 per 1000

    40 ÷ 2000 × 1000 = 20.

  22. In a year there are 5,000 live births and 150 infant deaths. The IMR is

    1. 15 per 1000
    2. 50 per 1000
    3. 30 per 1000
    4. 3 per 1000
    Answer

    C. 30 per 1000

    150 ÷ 5000 × 1000 = 30.

  23. A village has 800 live births and 24 neonatal deaths. What is the neonatal mortality rate?

    1. 30 per 1000
    2. 24 per 1000
    3. 3 per 1000
    4. 80 per 1000
    Answer

    A. 30 per 1000

    24 ÷ 800 × 1000 = 30.

  24. A baby weighs 3 kg at birth. Approximately what weight is expected at one year?

    1. 12 kg
    2. 9 kg
    3. 15 kg
    4. 6 kg
    Answer

    B. 9 kg

    Birth weight triples by 1 year: 3 × 3 = 9 kg.

  25. A child shows a social smile at about the age of

    1. 2 months
    2. 6 months
    3. 9 months
    4. 12 months
    Answer

    A. 2 months

    Social smile appears at about 6 to 8 weeks.

  26. A child usually sits without support at

    1. 4 months
    2. 14 months
    3. 2 months
    4. 8 to 9 months
    Answer

    D. 8 to 9 months

    Sitting alone comes at 8 to 9 months.

  27. A child usually walks alone at about

    1. 24 months
    2. 6 months
    3. 12 to 15 months
    4. 8 months
    Answer

    C. 12 to 15 months

    Independent walking is at 12 to 15 months.

  28. Kangaroo mother care is mainly beneficial for

    1. Children above 5 years
    2. Adolescents
    3. Low birth weight babies
    4. Pregnant women
    Answer

    C. Low birth weight babies

    Skin-to-skin contact keeps small babies warm.

  29. The maximum Apgar score is

    1. 5
    2. 20
    3. 7
    4. 10
    Answer

    D. 10

    Five signs, each scored 0 to 2.

  30. The 4 Ds screened under RBSK include

    1. Diabetes, dengue, diarrhoea, disability
    2. Defects at birth, diseases, deficiencies and developmental delays
    3. Dental, diabetes, dust, dengue
    4. Diet, drugs, drink, disease
    Answer

    B. Defects at birth, diseases, deficiencies and developmental delays

    RBSK covers these four groups.

  31. Which is a danger sign needing urgent referral in a newborn?

    1. Chest indrawing
    2. Passing stool several times
    3. Sleeping after feeding
    4. Sneezing
    Answer

    A. Chest indrawing

    Chest indrawing signals severe respiratory illness.

  32. Statements: 1. A child with mild fever can be vaccinated. 2. A severe allergic reaction to a previous dose is a contraindication. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct.

  33. Statements: 1. BCG is given on the left upper arm. 2. MR vaccine is given subcutaneously on the right upper arm. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are standard sites.

  34. Statements: 1. Colostrum is rich in antibodies. 2. Water should be given to babies before 6 months. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Exclusive breastfeeding means nothing else, not even water.

  35. Statements: 1. OPV is a live vaccine. 2. OPV is given by injection. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    OPV is given as oral drops.

  36. Statements: 1. Birth weight doubles by 5 months. 2. Birth weight triples by 1 year. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are standard growth facts.

  37. Statements: 1. A vaccine vial monitor shows heat exposure. 2. Vaccines should be kept in the refrigerator door. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    The door is the warmest part and not recommended.

  38. Statements: 1. Zinc is given in diarrhoea for 14 days. 2. ORS is mixed in one litre of clean water. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are standard.

  39. Match the vaccine with the site: 1. BCG, 2. Pentavalent, 3. Measles-rubella. Which set is correct?

    1. 1 mid-thigh intramuscular, 2 left upper arm intradermal, 3 right upper arm subcutaneous
    2. 1 left upper arm intradermal, 2 mid-thigh intramuscular, 3 right upper arm subcutaneous
    3. 1 right upper arm subcutaneous, 2 mid-thigh intramuscular, 3 left upper arm intradermal
    4. 1 left upper arm intradermal, 2 right upper arm subcutaneous, 3 mid-thigh intramuscular
    Answer

    B. 1 left upper arm intradermal, 2 mid-thigh intramuscular, 3 right upper arm subcutaneous

    Each vaccine has a fixed route and site.

  40. Match the vaccine with its type: 1. BCG, 2. Tetanus, 3. Hepatitis B. Which set is correct?

    1. 1 recombinant subunit, 2 toxoid, 3 live attenuated
    2. 1 toxoid, 2 live attenuated, 3 recombinant subunit
    3. 1 live attenuated, 2 recombinant subunit, 3 toxoid
    4. 1 live attenuated, 2 toxoid, 3 recombinant subunit
    Answer

    D. 1 live attenuated, 2 toxoid, 3 recombinant subunit

    BCG is live, tetanus is toxoid, hepatitis B is recombinant.

  41. Match the age with the vaccine: 1. Birth, 2. 9 to 12 months, 3. 16 to 24 months. Which set is correct?

    1. 1 MR-1, 2 BCG, 3 DPT booster
    2. 1 DPT booster, 2 BCG, 3 MR-1
    3. 1 BCG, 2 DPT booster, 3 MR-1
    4. 1 BCG, 2 MR-1, 3 DPT booster
    Answer

    D. 1 BCG, 2 MR-1, 3 DPT booster

    BCG at birth, MR-1 at 9 to 12 months, DPT booster at 16 to 24 months.

  42. Statements: 1. Fast breathing cut-off falls as the age rises. 2. Chest indrawing is a danger sign. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Cut-offs are 60, 50 and 40.

  43. Statements: 1. Pregnant women get Td. 2. Pregnant women get BCG. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    BCG is for newborns.

  44. Statements: 1. Mission Indradhanush aims to reach missed children. 2. Reconstituted measles-rubella vaccine can be kept for a week. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    It must be used within 4 hours.

  45. Statements: 1. Auto-disable syringes prevent reuse. 2. Freeze-sensitive vaccines include DPT and Td. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct.

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