Pediatric Nursing Notes: Milestones, Immunisation, IMNCI, ORS and Malnutrition

These pediatric nursing notes cover the child health topics that are tested most often in AIIMS NORCET, staff nurse, CHO and ANM exams: growth and development milestones, the national immunisation schedule, IMNCI, newborn reflexes, common childhood illnesses, dehydration and ORS, malnutrition, congenital anomalies and drug dose calculation. Child health is a consistent, high-scoring subject, and milestone and vaccine questions are almost guaranteed.

Newborn care at birth is covered in our obstetrics and gynaecology nursing notes, and child nutrition links closely with our nutrition nursing notes.

Pediatric nursing notes: scope and weightage

Pediatrics usually carries a steady share of questions in NORCET and staff nurse exams, while CHO and ANM papers focus on immunisation, IMNCI, diarrhoea, nutrition and growth monitoring. Standard references are Wong’s Essentials of Pediatric Nursing, O.P. Ghai Essential Pediatrics and Ministry of Health guidelines for the UIP and IMNCI.

Growth: key numbers

Parameter	Key facts
Weight	Birth weight is regained by about 10 days, doubles by about 5 months, triples by 1 year and is about four times by 2 years
Length / height	About 50 cm at birth, 75 cm at 1 year, and doubles (about 100 cm) by 4 years
Head circumference	About 33 to 35 cm at birth, about 45 to 46 cm at 1 year; chest circumference equals head circumference around 1 year
Fontanelles	Posterior closes by 6 to 8 weeks; anterior closes by 12 to 18 months
Teeth	First tooth (lower central incisor) erupts at about 6 months; 20 milk teeth complete by about 2.5 years; first permanent tooth (first molar) at 6 years; 32 permanent teeth

Developmental milestones

Age	Gross motor	Fine motor / language / social
2 months	Lifts head briefly in prone	Social smile
3 months	Head holding (neck control)	Cooing; recognises mother
4 to 5 months	Rolls over	Reaches for objects with both hands
6 months	Sits with support	Transfers objects hand to hand; monosyllables (ba, da); stranger anxiety begins
8 months	Sits without support	Babbling
9 months	Crawls, stands with support	Immature pincer grasp; bisyllables (mama, dada); waves bye-bye
12 months	Walks with support, stands alone	Mature pincer grasp; 1 to 2 meaningful words
13 to 15 months	Walks alone	Tower of 2 cubes; scribbles
18 months	Runs, climbs stairs with help	Feeds self with spoon; vocabulary grows
2 years	Climbs up and down stairs	2 to 3 word sentences; tower of 6 cubes
3 years	Rides a tricycle	Knows full name and gender; copies a circle
4 years	Hops on one foot	Copies a cross; tells a story
5 years	Skips	Copies a triangle

Theories of development

Stage	Freud	Erikson	Piaget
Infant (0 to 1 year)	Oral	Trust vs mistrust	Sensorimotor (0 to 2 years)
Toddler (1 to 3 years)	Anal	Autonomy vs shame and doubt	Preoperational begins (2 to 7 years)
Preschool (3 to 6 years)	Phallic	Initiative vs guilt	Preoperational
School age (6 to 12 years)	Latency	Industry vs inferiority	Concrete operational (7 to 11 years)
Adolescent	Genital	Identity vs role confusion	Formal operational (11 years onwards)

Separation anxiety during hospitalisation is most marked in toddlers and passes through three stages: protest, despair and detachment (denial).

National immunisation schedule (UIP)

The table below follows the national immunisation schedule as published by the Government of India (PIB backgrounder, March 2026). The UIP protects against 12 diseases: tuberculosis, diphtheria, pertussis, tetanus, polio, measles, rubella, hepatitis B, Hib infections, rotavirus diarrhoea, pneumococcal disease and Japanese encephalitis (in endemic districts).

Age	Vaccines
Birth	BCG, OPV-0, Hepatitis B birth dose (within 24 hours)
6 weeks	OPV-1, Pentavalent-1, Rotavirus-1, fIPV-1, PCV-1
10 weeks	OPV-2, Pentavalent-2, Rotavirus-2
14 weeks	OPV-3, Pentavalent-3, Rotavirus-3, fIPV-2, PCV-2
9 to 12 months	MR-1, JE-1 (endemic districts), PCV booster, Vitamin A first dose
16 to 24 months	MR-2, JE-2, DPT booster-1, OPV booster, Vitamin A second dose
5 to 6 years	DPT booster-2
10 years and 16 years	Td
Pregnant women	Td-1, Td-2 or Td booster

Routes, doses and sites

• BCG: 0.1 ml (0.05 ml below 1 month of age) intradermal, left upper arm; can be given up to 1 year.
• OPV: 2 drops oral. Rotavirus vaccine: oral (5 drops for Rotavac).
• Hepatitis B, Pentavalent (DPT + Hep B + Hib), PCV: 0.5 ml IM, anterolateral thigh.
• fIPV: 0.1 ml intradermal, right upper arm.
• MR and JE: 0.5 ml subcutaneous (MR right upper arm, JE left upper arm).
• Vitamin A: 1 lakh IU at 9 months, then 2 lakh IU every 6 months up to 5 years (9 doses in total).

Cold chain: vaccines are stored at 2 to 8 degrees C in the ice-lined refrigerator at the PHC level. The vaccine vial monitor (VVM) shows cumulative heat exposure; discard the vial when the inner square matches or is darker than the outer circle. Freeze-sensitive vaccines are checked with the shake test. In addition, a nationwide HPV vaccination campaign for 14-year-old girls was launched on 28 February 2026, as per the same PIB backgrounder.

IMNCI basics

Integrated Management of Neonatal and Childhood Illness (IMNCI) is India’s adaptation of WHO’s IMCI. It covers young infants (up to 2 months) and children aged 2 months to 5 years. The case management process is: assess, classify, identify treatment, treat, counsel and follow up.

• Colour coding: pink means urgent referral, yellow means specific treatment at the facility, green means home management.
• General danger signs (2 months to 5 years): not able to drink or breastfeed, vomits everything, has had convulsions, lethargic or unconscious, convulsing now.
• Fast breathing cut-offs: below 2 months 60 or more per minute; 2 to 12 months 50 or more; 12 months to 5 years 40 or more.
• Chest indrawing and danger signs point to severe disease needing referral.

Newborn assessment and reflexes

Normal term newborn: weight 2.5 to 4 kg, length about 50 cm, heart rate 120 to 160 per minute, respiratory rate 40 to 60 per minute. Meconium and urine are usually passed within the first 24 hours. Physiological jaundice appears after 24 hours; jaundice in the first 24 hours is always pathological.

Reflex	How elicited	Disappears by
Moro (startle)	Sudden head drop; arms abduct and extend, then embrace	3 to 6 months
Rooting	Stroke the cheek; baby turns towards the touch	3 to 4 months
Sucking	Touch the lips	Becomes voluntary in infancy
Palmar grasp	Object placed in palm	3 to 4 months
Plantar grasp	Pressure on sole below toes	8 to 12 months
Asymmetric tonic neck (fencing)	Head turned to one side	4 to 6 months
Stepping (walking)	Baby held upright, feet touching a surface	About 2 months
Babinski	Stroke the lateral sole; toes fan out with dorsiflexion of the great toe	Normal up to 1 to 2 years

Persistence of primitive reflexes beyond the expected age suggests neurological problems such as cerebral palsy.

Common childhood illnesses

Condition	Key exam points
Pneumonia (ARI)	Leading infectious cause of under-5 deaths; fast breathing and chest indrawing; oral amoxicillin under IMNCI
Measles	Koplik spots, rash from behind the ears; give Vitamin A
Febrile seizures	6 months to 5 years, with fever, usually generalised and brief
Nephrotic syndrome	Massive proteinuria, hypoalbuminaemia, oedema, hyperlipidaemia; treated with prednisolone
Acute glomerulonephritis	Follows streptococcal infection; haematuria (cola-coloured urine), hypertension, oedema
Rheumatic fever	Follows streptococcal pharyngitis; Jones criteria; penicillin prophylaxis
Worm infestation	Albendazole (400 mg; 200 mg for 1 to 2 years); National Deworming Day

Dehydration assessment and ORS

Classification (IMNCI)	Signs (two or more)	Treatment
Severe dehydration	Lethargic or unconscious, sunken eyes, not able to drink or drinking poorly, skin pinch goes back very slowly (more than 2 seconds)	Plan C: IV Ringer’s lactate 100 ml/kg
Some dehydration	Restless and irritable, sunken eyes, drinks eagerly (thirsty), skin pinch goes back slowly	Plan B: ORS 75 ml/kg over 4 hours
No dehydration	Not enough signs for the above	Plan A: home management with ORS and zinc

• Plan C timing: infants below 12 months: 30 ml/kg in 1 hour, then 70 ml/kg in 5 hours. Children 12 months to 5 years: 30 ml/kg in 30 minutes, then 70 ml/kg in 2.5 hours.
• Plan A: ORS after each loose stool: below 2 years 50 to 100 ml; 2 to 10 years 100 to 200 ml.
• Zinc: 10 mg daily for infants 2 to 6 months and 20 mg daily for children above 6 months, for 14 days.
• Low osmolarity ORS (WHO): total osmolarity 245 mOsm/L. Per litre: sodium chloride 2.6 g, glucose (anhydrous) 13.5 g, potassium chloride 1.5 g, trisodium citrate dihydrate 2.9 g. Use within 24 hours of preparation.

Nutrition and malnutrition

Exclusive breastfeeding is recommended for the first 6 months, with complementary feeding from 6 months and continued breastfeeding up to 2 years or beyond. Colostrum is rich in IgA and vitamin A.

Category (6 to 59 months)	Criteria
Severe acute malnutrition (SAM)	Weight-for-height below -3 SD, or MUAC below 11.5 cm, or bilateral pitting oedema
Moderate acute malnutrition (MAM)	Weight-for-height between -3 and -2 SD, or MUAC 11.5 to below 12.5 cm
Stunting	Height-for-age below -2 SD (chronic malnutrition)
Wasting	Weight-for-height below -2 SD (acute malnutrition)
Underweight	Weight-for-age below -2 SD

• Kwashiorkor: oedema, flaky-paint dermatosis, moon face, hair changes (flag sign), fatty liver; mainly protein deficiency.
• Marasmus: severe wasting, “old man” face, no oedema; deficiency of overall calories.
• SAM with complications is managed at Nutrition Rehabilitation Centres following the WHO 10 steps (treat hypoglycaemia, hypothermia and dehydration first; start with F-75 and move to F-100 for catch-up growth).
• Vitamin A deficiency: night blindness is the earliest symptom; Bitot’s spots are seen on the conjunctiva.

Congenital anomalies

Anomaly	Key points
Cleft lip / cleft palate	Lip repair around 3 months (“rule of 10s”); palate repair around 9 to 18 months, before speech develops; special feeding techniques
Tracheo-oesophageal fistula	Excess frothing and drooling, choking, coughing and cyanosis with feeds; commonest type is oesophageal atresia with distal fistula
Hypertrophic pyloric stenosis	Projectile non-bilious vomiting at 2 to 8 weeks, olive-shaped mass, metabolic alkalosis; Ramstedt pyloromyotomy
Hirschsprung disease	Absent ganglion cells in the colon; failure to pass meconium within 48 hours, abdominal distension
Intussusception	Colicky pain, “red currant jelly” stools, sausage-shaped mass
Ventricular septal defect	Most common congenital heart disease (acyanotic)
Tetralogy of Fallot	Most common cyanotic CHD: VSD, pulmonary stenosis, overriding aorta, right ventricular hypertrophy; boot-shaped heart; knee-chest position for tet spells
Patent ductus arteriosus	Machinery murmur; closure with indomethacin or ibuprofen in preterms
Neural tube defects	Spina bifida, meningocele, meningomyelocele; prevented by periconceptional folic acid; protect the sac with sterile moist dressing
Down syndrome	Trisomy 21; simian crease, upslanting eyes, hypotonia

Pediatric drug dose basics

• Young’s rule: child dose = age in years / (age + 12) x adult dose.
• Clark’s rule: child dose = weight in pounds / 150 x adult dose.
• Fried’s rule (infants): child dose = age in months / 150 x adult dose.
• Body surface area method (most accurate): child dose = BSA (m2) / 1.73 x adult dose.
• In practice most drugs are dosed per kg; for example paracetamol 10 to 15 mg/kg per dose every 4 to 6 hours.
• Maintenance fluids (Holliday-Segar): 100 ml/kg/day for the first 10 kg, 50 ml/kg/day for the next 10 kg, 20 ml/kg/day for each kg above 20. A 15 kg child needs 1,000 + 250 = 1,250 ml per day.

Quick revision points

• Birth weight doubles at about 5 months and triples at 1 year.
• Head holding: 3 months. Sitting without support: 8 months. Walking alone: 13 months.
• Social smile: 2 months. Pincer grasp: 9 to 12 months.
• Anterior fontanelle closes by 12 to 18 months.
• Erikson’s stage for toddlers: autonomy vs shame and doubt.
• BCG is given intradermally in the left upper arm.
• Pentavalent vaccine protects against diphtheria, pertussis, tetanus, hepatitis B and Hib.
• MR first dose is given at 9 to 12 months.
• Fast breathing in a child aged 12 months to 5 years: 40 or more per minute.
• Plan B ORS: 75 ml/kg over 4 hours.
• Osmolarity of low osmolarity ORS: 245 mOsm/L.
• Zinc for diarrhoea is given for 14 days.
• SAM: MUAC below 11.5 cm.
• Moro reflex disappears by 3 to 6 months.
• Most common cyanotic heart disease: tetralogy of Fallot.
• Projectile non-bilious vomiting with olive mass: pyloric stenosis.
• Young’s rule: age / (age + 12) x adult dose.

Revise these facts with the NORCET test series and the CHO test series. For immunisation and child health programmes, also read our national health programmes notes and community health nursing notes. ANM aspirants can check the ANM exam pattern and syllabus and our ANM courses, while NORCET aspirants can explore the AIIMS NORCET courses.

Frequently asked questions

Which pediatric topics are most important for nursing exams?

Growth and developmental milestones, the immunisation schedule, IMNCI, dehydration and ORS, malnutrition criteria, newborn reflexes and congenital heart disease are the most frequently asked areas.

How should I remember developmental milestones?

Learn one key milestone per age in each domain (gross motor, fine motor, language and social) using the table above, then practise MCQs. Exams mostly ask about head holding, sitting, walking, social smile, pincer grasp and first words.

Is the immunisation schedule asked in CHO and ANM exams?

Yes, very often. Questions cover the age of each vaccine, route, dose, site, cold chain and Vitamin A supplementation, so learn the UIP table thoroughly.

What is the difference between SAM and MAM?

SAM is weight-for-height below -3 SD, MUAC below 11.5 cm or bilateral pitting oedema. MAM is weight-for-height between -3 and -2 SD or MUAC from 11.5 to below 12.5 cm.

Which book is best for pediatric nursing?

Wong’s Essentials of Pediatric Nursing and O.P. Ghai Essential Pediatrics are standard references. Use Ministry of Health guidelines for the UIP, IMNCI and nutrition programmes.