DR NISHANT PRABHAKAR MD PEDIATRICS

ADOLESCENT IN INDIA
 India is home to 243 million adolescents –
children aged 10 to 19 years – the most
adolescents of any country.
 It accounts for about 21.3% of population of
the country.
 Girls currently married (age group 15-19yr) are
30%.
 Boys currently married (age group 15-19yr)
are 4.6%.
 Birth by age 18 year- 21.7%
UNICEF GLOBAL DATA 2011
BURDEN OF HEALTH
PROBLEM
 An estimated 1.3 million adolescents died in 2012,
mostly from preventable or treatable causes.
 Road traffic injuries were the leading cause of
death in 2012, with some 330 adolescents dying
every day.
 Other main causes of adolescent deaths include
HIV, suicide, lower respiratory infections and
interpersonal violence.
 Half of all mental health disorders in adulthood
appear to start by age 14, but most cases are
undetected andUNICEF
untreated.
GLOBAL DATA 2011
 VULNERABLE
 Adolescence is a time of immense biologic,
psychological, and social change. These rapid
changes in hormonal milieu, changing ideas and
concepts about the world, having to cope up
with the expectations from the society and need
to establish their own identity keep them in lots
of pressure.

GHAI 8TH EDITION PG 63-69

ADOLESCENT NUTRITION
 Nearly half of adolescent girls aged 15–19 in
India are underweight, with a body mass index
of less than 18.5.(unicef global database 2011)
 ADOLESCENT NUTRITION
(Cont…)
 There is increase in nutritional requirement during this
period of rapid growth micronutrient being as important
as energy and protein.
 Lack of sun exposure with modest tradition of clothing
coupled with dark skin pigment causes vitamin D
deficiency.
 Insufficient dairy product intake in underprivileged girls
leads to poor intake of protein and calcium resulting low
bone mineral density.
 Vitamin A deficiency is also an important issue in
economically deprived adolescents.
 Undernutrition often delays the onset of puberty and
sexual maturation, and result in stunting, poor bone
mass accrual and reduced work capacity. GHAI 8TH EDITION PG 63-69
ADOLESCENT NUTRITION
(Cont…)

Adolescent Nutrition: A Review of the Situation in Selected South-East Asian

Countries (WHO)
ADOLESCENT NUTRITION
(Cont…)
 A large proportion of India’s adolescents are
anaemic: 56 per cent of girls and 30 per cent of
boys.
 Anaemia among adolescents adversely affects
these young people’s growth, resistance to
infections, cognitive development and work
productivity.
 The national Ministry of Health and Family
Welfare (MHFW) launched a nationwide Weekly
Iron and Folic Acid Supplementation (WIFS)
programme in January 2013.
Public Health Nutrition 2013; 16 (09): 1667-1676
ADOLESCENT NUTRITION
(Cont…)
The services delivered under scheme:-
1) weekly iron and folic acid supplementation;
2) bi-annual deworming; and
3) nutrition counselling about how to improve diet,
prevent anaemia and minimize the potential side-
effects of IFA supplementation and deworming.
 Kishori shakti yojna to improve nutritional and
health status of girls in age group of 11-18 years.
 Improving nutritional status of adolescent girls
helps break the cycle of malnutrition and low birth
weight babies.

Public Health Nutrition 2013; 16 (09): 1667-1676

 EATING DISORDERS
 ANOREXIA NERVOSA:- m/c among 15-19yr
old.
 Charecterized by-
 Body weight <85% of expected weight for age
and height
 Intense fear of becoming fat even though
underweight.
 Disturbed body image and denial that current
body weight is low
 In postmenarcheal girls, amenorrhea.

 Anorexia is commonly associated with

depression, anxiety,
GHAI 8THsuicidal ideation and/or
EDITION PG 63-69
EATING DISORDERS (Cont…)
 Profound weight loss may result in hypothermia,
hypotension, dependent edema, bradycardia,
hypokalemic metabolic alkalosis.
 Mortality is attributed to cachexia and suicide.
 MANAGEMENT-
 Psychotherapy (individual + family therapy) to
establish appropriate eating pattern and normal
perception of hunger and satiety.
 Nutritional rehabilitation (in severe cases
NG/Parenteral nutrition)
 Antidepressant and antipsychotic drugs as required.

GHAI 8TH EDITION PG 57

EATING DISORDERS (Cont…)
 BULIMIA:- more common in girls between 10-19
yr of age. Charecterized by
 Recurrent episodes of binge eating
 Recurrent inappropriate compensatory behavior to
prevent weight gain, such as self induced vomitting,
misuse of laxatives, diuretics enemas, fasting or
excessive exercise
 both at least twice a week for 3 months.

 Affected patients have comorbidities like

depression and psychosis.
 MANAGEMENT:- combination of psychotherapy
and antidepressants (such as fluoxetine)
GHAI 8TH EDITION PG 57
MENTAL HEALTH PROBLEMS
 Depression is the top cause of illness and
disability among adolescents and suicide is the
third cause of death.
 Adjustment disorder, anxiety disorder, delinquent
behavior, poor body image, and low self-esteem
are other psychological problems.
 Completed suicides are higher in boys
 Attempted suicides are higher in girls
 Adolescents are at higher risk of committing
suicide because of their cognitive immaturity and
increased impulsivity.
GHAI 8TH EDITION PG 63-69
MENTAL HEALTH PROBLEMS
(Cont…)
 Building life skills in children and adolescents
and providing them with psychosocial support
in schools and other community settings can
help promote good mental health.
 Programmes to help strengthen ties between
adolescents and their families are also
important.
 If problems arise, they should be detected and
managed by competent and caring health
workers. GHAI 8TH EDITION PG 63-69
EARLY PREGNANCY &
CHILD BIRTH
 Complications linked to pregnancy and childbirth
are the second cause of death for 15-19-year-old
girls globally.
 Every year, some 3 million girls aged 15 to 19
undergo unsafe abortions.
 Babies born to adolescent mothers face a
substantially higher risk of dying than those born
to women aged 20 to 24.
 Unmarried adolescents are likely to resort to
unsafe method of abortions, which increases the
risk of complication like septicemia and also
mortality.
GHAI 8TH EDITION PG 63-69
EARLY PREGNANCY & CHILD BIRTH
(Cont…)
 Adolescent pregnancy are also at increased
risk of pre-eclampsia, preterm labor, prolonged
and obstructed labor, and postpartum
hemorrhage. And such pregnancies are 2 to 4
times likely to die during childbirth as
compared to adult pregnancies.
 Many girls who become pregnant have to drop
out of school.
 Newborns born to adolescent mothers are also
more likely to have low birth weight, with the
risk of long-term effects.
GHAI 8TH EDITION PG 63-69
EARLY PREGNANCY &
CHILD BIRTH (Cont…)
 WHO published guidelines in 2011 with the UN
Population Fund (UNFPA) on preventing early
pregnancies and reducing poor reproductive
outcomes with 6 main objectives:
 reducing marriage before the age of 18;
 creating understanding and support to reduce pregnancy
before the age of 20;
 increasing the use of contraception by adolescents at risk
of unintended pregnancy;
 reducing coerced sex among adolescents;
 reducing unsafe abortion among adolescents;
 increasing use of skilled antenatal, childbirth and postnatal
care among adolescents.
UNICEF UPDATE SEPTEMBER 2012
 GENDER DYSPHORIA
 According to DSM 5 criteria a marked incongruence
between one’s experienced/expressed gender and
assigned gender, of at least 6 month duration as
manifested by at least 2 of the following:
 Incongruence in experienced and assigned gender
 Strong desire to be rid of one’s secondary sex characteristics
 Strong desire of secondary sex characteristics of other gender
 Strong desire to be other gender
 Strong desire to be treated as other gender
 Strong conviction that one has feelings and reaction of the
other gender.
 The condition is a/w clinically significant distress or
impairment in social and occupational functioning
NELSON 20TH EDITION PG 931-936
GENDER DYSPHORIA
(Cont…)
 To alleviate socially induced distress, interventions
focus on stigma management and stigma
reduction.
 The main goal is not to change the child’s gender
variant behavior but to assist families, school, and
the wider community to create a supportive
environment in which the child can thrive and
safely explore his or her gender identity and
expression.
 Medical interventions are available as early as
tanner stage 2. such treatment is guided by the
standards NELSON
of care setPG 931-936
20TH EDITION forth by the world
professional association for transgender health
SLEEP DISTURBNCE
 During the period of rapid growth, adolescents
have increased sleep requirement.
 But they are deprived of sleep due to increased
academic activity, parents working in shift or
watching TV late into the night.
 Inadequate sleep may cause poor school
performance , daytime drowsiness, aggressive
behavior, conduct disorder, anxiety, restless leg
syndrome and depression.
 Sleep deprived teens may have periods of
subconscious bouts of sleep during the daytime,
making them prone to injuries and accidents.
GHAI 8TH EDITION PG 63-69
SEXUALLY TRANSMITTED
INFECTIONS
 Early sexual activity is not uncommon in India.
 Various biological (immature and incompletely
estrogenised mucosa) and psychological factors
(lack of preparedness, lack of familiarity with
barrier contraceptives) make an adolescent
susceptible to these infections.
 Vaginal discharge is common in adolescent girls
and may signify physiological leucorrhea of
puberty or endogenous or sexually transmitted
infections.
 Pelvic inflammatory disease (PID) is a spectrum
of inflammatory disorder of female genital tract. It
can present with abdominal pain and vaginal
discharge. GHAI 8TH EDITION PG 63-69
SEXUALLY TRANSMITTED
INFECTIONS(Cont…)
 Gonorrhea- vulvovaginitis, urethritis or
proctitis- ceftriaxone 125mg iv or im single
dose.

GONOCOCCAL
GONOCOCCAL URETHRAL CERVICITIS
DISCHARGE
GHAI 8TH EDITION PG 63-69
SEXUALLY TRANSMITTED
INFECTIONS(Cont.)
 Chlamydia- urethritis, vaginal discharge- oral
azithromycin 1g single dose, or doxycycline
100mg twice daily for 14 days.
 Herpes – multiple painful vesicles and ulcers;
tend to recur- oral acyclovir 400mg thrice daily
for 7 days

GHAI 8TH EDITION PG 63-69

SEXUALLY TRANSMITTED
INFECTIONS(Cont…)
 Primary syphilis- painless genital ulcer-
benzathine penicillin 2.4 MU IM (after test
dose); oral doxycycline if allergic to penicillin.

 Genital warts (papilloma virus)- tend to recur-

Local application of podophylline weekly,
cryotherapy or surgical removal; preventable
with vaccination.
GHAI 8TH EDITION PG 63-69
SEXUALLY TRANSMITTED
INFECTIONS(Cont…)
 Chancroid- painful ulcer with
lymphadenopathy- oral azithromycin single
dose or ciprofloxacin 500mg twice daily for 3
days.
 Trichomoniasis – malodorous yellow green
discharge- oral metronidazole or tinidazole 2g
single dose.

GHAI 8TH EDITION PG 63-69

SEXUALLY TRANSMITTED
INFECTIONS(Cont…)
 Candidiasis – itching, redness, white discharge-
Clotrimazole cream or pessary for 7 days,
metronidazole 400mg orally twice daily for 14
days and doxycycline 100mg twice daily for 14
days; abstinence; symptomatic treatment (any
severe disease or mild to moderate not
responding to above- i/v antibiotic)
 Pediculosis pubis- pruritus- local application of 1%
permethrine, wash after 10 min
 Scabies- Pruritus and rash- local application of
permethrin or oral ivermectin 2 doses 14 days
apart
GHAI 8TH EDITION PG 63-69
SEXUALLY TRANSMITTED
INFECTIONS(Cont…)
 HIV-
 More than 2 million adolescents are living with
HIV
 Although HIV deaths decreased in last 8 years
but adolescents deaths are rising.
 Young people need to know how to protect
themselves and have the means to do so. This
includes being able to obtain condoms to
prevent sexual transmission of the virus and
clean needles and syringes for those who
inject drugs. Better access to HIV testing and
counselling isGHAI
also needed.
8TH EDITION PG 63-69
OBESITY
 Among delhi school children, 5% obesity and 17-
19% overweight has been reported. Similar
figures are available from other parts of the urban
India as well.
 Prevalence of obesity and overweight is higher in
boys than in girls.
 Obesity has strong association with asthma, sleep
disorder, reflux disease, blount disease, slipped
femoral epiphysis, gallstones, fatty liver, and
numerous metabolic derangements like type 2
diabetes, dyslipidemia, hypertension and
polycystic ovarian disease.
GHAI 8TH EDITION PG 63-69
OBESITY (Cont…)
 Change in sedentary life style, decrease
consumption of calorie dense food and
increase outdoor activity contribute to these
disorders.

GHAI 8TH EDITION PG 63-69

GYENECOLOGICAL
PROBLEMS
 It is common to have anovulatory and irregular
menstrual cycles during first two years after
menarche.
 In polycystic ovarian syndrome, with a
combination of menstrual irregularities and
ovarian cyst with androgen excess like acne or
hirsutism, occurs in around 9% of Indian
adolescent girls. The condition has association
with other metabolic derangements like
obesity, insulin resistance and type 2 diabetes.
GHAI 8TH EDITION PG 63-69
SUBSTANCE ABUSE
 Most of the tobacco and alcohol use starts
during adolescence.
 Alcohol(21%), Tobacco(14%), cannabis(3%),
and opium (0.4%) are the most prevalent
substance abuse in Indian adolescence.
 Addicts are more prone to accidents, injuries,
violence, trading sex for drugs, HIV, hepatitis
C, sexually transmitted disease and
tuberculosis.

GHAI 8TH EDITION PG 63-69

VIOLENCE
 WHO defines violence as
 “The intentional use of physical force or power,
threatened or actual, against oneself, another
person, or against a group or community that
either results in or has a high likelihood of
resulting in injury, death, psychologic harm,
maldevelopment or deprivation”
 Physical and sexual violence are common in
India.
 20-30% of young females suffering from domestic
violence and 5-9% young females reporting
sexual violence (NFHS3).
 Motor vehicle and industrial accidents are
common in boysGHAIwhereas burns
8TH EDITION PG 63-69 are common in
VIOLENCE (Cont…)
 The FISTS mnemonic provides guidance for
structuring the assessment of violence-

NELSON 20TH EDITION PG 946

 VIOLENCE (Cont…)
 Multiple treatment modalities are used
simultaneously in managing adolescents with
persistent violent and aggressive behavior and
range from cognitive-behavioral therapy involving
the individual and family to specific family
interventions (parent management training,
multisystemic treatment) and pharmacotherapy.
 Treatment of existing comorbid conditions, such
as attention-deficit/hyperactivity disorder,
depression, and substance abuse, appears to
reduce aggressive behavior.
NELSON 20TH EDITION PG 946
LACK OF SEX EDUCATION
 The majority of Indian adolescent do not get
formal sex education in an effective way.
 Peers, books, internet and magazines are their
main source of information about sex.
 Parents and teachers often fail to discuss
issues like safe sex, dating, abortion, HIV, and
sexually transmitted diseases.

GHAI 8TH EDITION PG 63-69

SOCIAL CHALLENGES
 MEDIA
 With the availability of electronic media,
adolescents are exposed to information from all
across the world.
 This exposure is unsupervised because of
working parents and increasing use of electronic
gadgets.
 Due to inability to separate fact from fantasy,
adolescents succumb to the glamorous portrayal
of tobacco or alcohol consumption, unrealistic
expectations, physical aggression, destructive
behavior and unprotected sex. GHAI 8TH EDITION PG 63-69
SOCIAL
CHALLENGES
 PEER PRESSURE
 Peer formation is a part of adolescent social
development.
 Pressure for conforming to norms drive many of
their actions and decisions, including risk taking
behavior and initiation of substance abuse.
 POVERTY
 Children
belonging to poorer families are likely to
have inadequate diets, have higher chances of
having depression, antisocial behavior and
engaging in drugs or sexual activity at earlier
ages.
GHAI 8TH EDITION PG 63-69
SOCIAL CHALLANGES
 ILLITERACY
 Though situation is improving over the years, still
33% of Indian youth are not able to complete their
primary education.
 Female gender belonging to rural and poor
background are risk factor for illiteracy.
 EARLY MARRIAGE
 Though the legal age for marriage is 18 yr for
girls, many states still have the practice of
childhood and early marriage.
GHAI 8TH EDITION PG 63-69
SOCIAL CHALLANGES
 ACADEMIC AND EMOTIONAL STRESS
 Examinations cause significant physiological and
psychological stress.
 Apart from rapid changes in their body structures,
various other factors like peer acceptance,
discrimination, academic burden, parental
expectations, changing social environments
cause stress among adolescents.
 Some adolescents may face adjustment problems
resulting in various psychological and somatic
effects.
GHAI 8TH EDITION PG 63-69
SOCIAL CHALLANGES
 DISCRIMINATION
 Adolescent girls are often asked to limit their
outdoor or extracurricular activities and are not
involved in any decision making. They are
expected to do household work.
 Gender based discrimination is seen in education
and even food distribution

GHAI 8TH EDITION PG 63-69

ROLE OF HEALTH CARE
PROVIDER
 Identifying risk
 Establishing rapport
 Confidentiality
 Consent(<12, 12-18, >18)
 Nutritional intervention
 Providing health information
 Contraception

GHAI 8TH EDITION PG 63-69

ROLE OF HEALTH CARE
PROVIDER
 Referral to social services, psychological
evaluation and support
 National Commission for Protection of Child
Rights Act 2005 consider a person below 18 yr as
a child.
 It is mandatory for a health care provider to report
all cases of child abuse (even suspected) to the
chairperson of the commission (online/writing).
 Doctors are protected in case of erroneous
reporting but punishable if they fail to report.
GHAI 8TH EDITION PG 63-69
ROLE OF HEALTH CARE
PROVIDER
 Adolescent immunisation

GHAI 8TH EDITION PG 63-69

ROLE OF HEALTH CARE
PROVIDER
 Adolescent friendly health services
 Management of sexual violence
 Forensic examination and collection of blood or
body fluid samples by trained staff
 Care of injuries
 Prophylaxis against pregnancy
 Prophylaxis against sexually transmitted diseases
 Prophylaxis against HIV
 HBV vaccination if not immunised
 Psychological support

GHAI 8TH EDITION PG 63-69

 CHECKLIST FOR
ADOLESCENT HEALTH VISIT
 History from parents and adolescents
 History of presenting problem
 Parental concern on growth and development

 Academic success; school absenteeism

 Diet intake including calcium, protein and iron

intake; junk food
 Menstrual history; sleep problems

GHAI 8TH EDITION PG 63-69

CHECKLIST FOR ADOLESCENT
HEALTH VISIT (Cont…)
 History on questioning of adolescents
 Emotional problems; relationship with family and
peers
 Outlook toward physical and sexual changes

 Involvement in relationship or sexual activity

 Awareness about safe sex and contraception

 Specific problems related to sex organs

 Tobacco or other substance use

 Counsel and clear doubts on sensitive topics

GHAI 8TH EDITION PG 63-69

CHECKLIST FOR ADOLESCENT
HEALTH VISIT (Cont…)
 History on separate questioning of parents
 Relationshipwith family
 Level of communication on sensitive matters

 Physical examination
 Anthropometry

 Blood pressure, obesity, acanthosis

 Sexual maturity rating

 Signs of malnutrition, anemia and vitamin

deficiency
 Signs of skin and genital infection
GHAI 8TH EDITION PG 63-69
CHECKLIST FOR ADOLESCENT
HEALTH VISIT (Cont…)
 Level of general hygiene
 Signs of trauma; abuse

 Signs of drug abuse and tobacco abuse

 Counseling
 Nutritionalintervention
 Hygiene practices

 Building rapport between parents and

adolescents
 Providing information and sources on sex
education
GHAI 8TH EDITION PG 63-69
CHECKLIST FOR ADOLESCENT
HEALTH VISIT (Cont…)
 Investigations
 Hemoglobin level
 Blood sugar, lipid profile

 Genital swab

 Ultrasound of ovaries

GHAI 8TH EDITION PG 63-69

CHECKLIST FOR ADOLESCENT
HEALTH VISIT (Cont…)
 Referral
 Counselor

 Dietitian

 Psychiatrist

 Gynecologist

 Voluntary and confidential HIV testing

 Social services, child protection agencies, support
groups.

GHAI 8TH EDITION PG 63-69

THANK YOU