Common Childhood Diseases in India: A Clinic Doctor's Guide to Diagnosis and Management

Hand, Foot and Mouth Disease (HFMD)

HFMD has become one of the most common and rapidly increasing childhood illnesses seen in Indian paediatric OPDs, particularly in urban areas. It is caused by Enterovirus — most commonly Coxsackievirus A16 and Enterovirus 71 (EV71). EV71-associated HFMD can cause severe neurological complications in a small minority of cases.

Clinical presentation:

• Low-grade to moderate fever (37.5–39°C)
• Painful oral ulcers (aphthous-like lesions on buccal mucosa, tongue, palate) — the oral pain causes refusal to eat and drink
• Vesicular rash on palms, soles, and between fingers/toes — the classic diagnostic triad
• Less commonly: rash on buttocks, knees, and elbows
• Incubation period 3–6 days. Highly contagious via oral-fecal route and respiratory droplets

Management: HFMD is almost always self-limiting and resolves in 7–10 days. No specific antiviral treatment exists. Focus on:

• Pain management for oral ulcers: lidocaine gel (2%) applied sparingly to mouth sores (avoid in infants under 2 years — seizure risk from systemic absorption); magic mouthwash (equal parts liquid antacid + diphenhydramine + water)
• Oral hydration: cold foods and liquids soothe the mouth — ice cream, cold milk, chilled ORS. Avoid acidic drinks (orange juice) which worsen mouth pain
• Paracetamol for fever and pain
• No school for 7 days from rash onset or until all vesicles have crusted

Red flags for EV71 severe HFMD (refer immediately): Persistent high fever beyond day 3, myoclonic jerks, ataxia, drowsiness, rapid heart rate or breathing disproportionate to fever, hypertension — these suggest neurological involvement (encephalitis, pulmonary oedema) requiring hospital admission.

Chickenpox (Varicella)

Despite an effective vaccine being available since the 1990s, chickenpox remains extremely common in Indian children due to low vaccination rates in the general population. Understanding the clinical course helps you counsel families accurately.

Clinical course:

• Prodrome (1–2 days before rash): Low-grade fever, malaise, mild headache. Not always present in children.
• Rash evolution: Starts on trunk, spreads to face and limbs. Classic: lesions in all stages simultaneously — macule → papule → vesicle → pustule → crust. New crops appear for 3–5 days. Highly pruritic.
• Infectious period: 2 days before rash appears until all lesions are crusted (typically day 6–7 after rash onset). Child must stay home from school until all crusts have formed.

Management in otherwise healthy children:

• Antihistamines (chlorphenamine syrup) for itch relief — helps children sleep
• Calamine lotion on lesions for itch and soothing
• Trim fingernails short — scratching introduces secondary bacterial infection
• Oatmeal baths (colloidal oatmeal) are soothing for widespread rash
• Paracetamol for fever — never aspirin
• Acyclovir (oral): IAP recommends it for immunocompetent children if started within 24 hours of rash onset — reduces severity and duration. Dose: 20 mg/kg/dose 4 times daily for 5 days

When to refer urgently — chickenpox complications:

• Secondary bacterial skin infection — increasing redness, warmth, pus, fever returning after initial improvement
• Pneumonia — cough, breathlessness, SpO2 drop (varicella pneumonia can be severe)
• Encephalitis — headache, vomiting, neck stiffness, altered consciousness, ataxia
• Any chickenpox in an immunocompromised child — requires IV acyclovir and hospitalisation
• Neonatal chickenpox (mother developed chickenpox within 5 days before or 2 days after delivery) — neonatal varicella can be fatal

Vaccination counselling: Varivax or Varilrix — 2 doses (12–15 months, then 4–6 years) offer >95% protection against disease and near-complete protection against severe disease. Strongly recommend at every OPD visit for unvaccinated children.

Measles: Clinical Diagnosis and Management

India has been working towards measles elimination, with MR vaccination coverage improving. However, cases continue to occur, particularly in underserved communities and during vaccination coverage gaps. Every clinic doctor should be able to diagnose measles clinically and know the mandatory reporting requirement.

The classic measles presentation — the 3 Cs + rash:

• Cough, Coryza (runny nose), Conjunctivitis — 2–4 days before the rash appears
• Koplik spots: Pathognomonic — tiny white spots like grains of salt on a red base on the buccal mucosa opposite the lower molars. Appear 1–2 days before rash and disappear as rash develops. Their presence confirms measles before the rash even appears.
• Rash: Starts behind ears and at the hairline, spreads downward over 3 days to cover face, trunk, limbs. Maculopapular, confluent. Lasts 5–7 days. Fades in the order it appeared.
• Fever: High, peaks when rash appears, resolves as rash fades.

Management: Supportive care — Vitamin A supplementation is mandatory in all confirmed measles cases in India (WHO recommendation reduces mortality and morbidity): 50,000 IU for infants under 6 months, 100,000 IU for 6–12 months, 200,000 IU for children above 12 months — two doses on consecutive days.

Complications to watch for: Otitis media (most common), pneumonia (most common cause of measles death), encephalitis (rare but serious), malnutrition worsening (measles causes immune suppression for weeks — watch for secondary infections).

Mandatory reporting: Measles is a notifiable disease under the National Disease Surveillance system. Report every confirmed or suspected case to the District Health Officer within 24 hours. This triggers outbreak investigation and vaccination campaign response.

Acute Diarrhoea in Children: Evidence-Based Management

Acute diarrhoea remains a leading cause of childhood morbidity in India. Despite decades of awareness campaigns, clinical management at the OPD level remains inconsistent. This is the evidence-based protocol that reduces complications and hospitalisation:

The two cornerstones of management — ORS and Zinc:

• ORS (Oral Rehydration Solution): WHO low-osmolarity ORS is the first-line treatment for all diarrhoea with any dehydration. Give 75 mL/kg over 4 hours for mild to moderate dehydration in clinic, then 10 mL/kg for each subsequent loose stool. Continue breastfeeding throughout. Do not dilute ORS or use homemade salt-sugar solutions (incorrect concentration is dangerous).
• Zinc supplementation: WHO and IAP recommend zinc for all children with diarrhoea — 20 mg/day for children above 6 months, 10 mg/day for infants below 6 months, for 14 days. Reduces duration and severity of current episode AND decreases incidence of diarrhoea for the next 3 months. Zinc is massively under-prescribed in Indian OPD practice despite strong evidence.

Antibiotics in acute diarrhoea — narrow indications only:

• Cholera: azithromycin or doxycycline (above 8 years)
• Bloody diarrhoea (dysentery) suspected to be bacterial: azithromycin
• Giardiasis: metronidazole
• Do NOT prescribe antibiotics for watery diarrhoea without blood or mucus — this is almost always viral (rotavirus, norovirus) and antibiotics do not help

Dehydration assessment — PLAN A / B / C:

• Plan A (no dehydration): ORS at home, zinc, continue feeds, return if worsening
• Plan B (some dehydration — sunken eyes, restless, drinks eagerly): ORS 75 mL/kg over 4 hours in clinic under observation, then reassess
• Plan C (severe dehydration — lethargic, unable to drink, skin pinch returns very slowly): IV Ringer's lactate 100 mL/kg (neonates) or 100 mL/kg for children — refer to hospital for IV rehydration

Febrile Seizures: What Parents and Doctors Need to Know

Febrile seizures affect 2–5% of children between 6 months and 6 years. They are the most common seizure type in childhood and are extraordinarily frightening for parents — even though the vast majority are benign and self-limiting.

Simple vs complex febrile seizure:

• Simple: Generalised (both sides of body), duration under 15 minutes, occurs once in 24 hours. No focal neurological signs after. 70–75% of all febrile seizures. Good prognosis.
• Complex: Focal (one side of body only), duration over 15 minutes, more than one seizure in 24 hours, or Todd's paralysis after. Requires full evaluation including EEG and neuroimaging.

Immediate management when parent brings child post-seizure:

• Assess: Is the child recovering normally? Neurological examination. Post-ictal drowsiness is normal for 20–30 minutes after seizure.
• Find and treat the fever cause — the seizure is a symptom of the fever
• Simple febrile seizure: No antiepileptic medication needed, no EEG required for first simple febrile seizure
• Lumbar puncture: Only if meningitis clinically suspected (neck stiffness, petechiae, photophobia, prolonged or complex seizure in ill-looking child)

Counselling parents after first febrile seizure: This is critical. Parents are terrified and often convinced their child has epilepsy. Address this directly: "A febrile seizure is triggered by fever, not by a brain condition. 70% of children never have another one. Of those who do have recurrences, they always happen only with fever. This type of seizure does not cause brain damage and does not mean your child will develop epilepsy." Give written information including first-aid steps for future seizures (safety, positioning, timing, do not restrain, call ambulance if over 5 minutes).

School Exclusion Periods: Quick Reference

Parents always ask "when can my child return to school?" — here are the standard guidelines:

• Chickenpox: Until all lesions are fully crusted — typically day 6–7 after rash onset
• Measles: Until day 5 after rash onset
• HFMD: Until all vesicles have crusted and child is fever-free — approximately 7 days from rash onset
• Influenza: Until fever-free for 24 hours without antipyretics
• Strep throat: 24 hours after starting antibiotics and fever-free
• Acute diarrhoea: Until 48 hours after last loose stool
• Conjunctivitis (infective): Until discharge has ceased or 24 hours after antibiotic eye drops started
• Mumps: Until 5 days after parotid swelling onset

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Frequently Asked Questions

Can a child get chickenpox if they have been vaccinated?

Yes, but rarely and usually very mildly. Breakthrough varicella in vaccinated children typically presents with fewer than 50 lesions, shorter illness, and no complications. One dose offers about 85% protection; two doses raise this to over 95%.

Is rotavirus vaccine still relevant after 2 years of age?

Rotavirus vaccine is given in infancy (6, 10, 14 weeks schedule in India under universal immunisation). It is not given after 8 months for the oral vaccine schedule. However, the protection it provides continues well into childhood — vaccinated children who do contract rotavirus have much milder disease.

A parent insists their child's recurring tonsillitis warrants tonsillectomy. How do I advise?

The Paradise criteria for tonsillectomy: 7 or more documented streptococcal tonsillitis episodes in 1 year, OR 5 or more per year for 2 consecutive years, OR 3 or more per year for 3 consecutive years. Refer to ENT if the child meets these criteria. Below this threshold, medical management and watchful waiting is the standard approach.

Should I prescribe probiotics for children with antibiotic-associated diarrhoea?

Lactobacillus rhamnosus GG and Saccharomyces boulardii have the strongest evidence for preventing antibiotic-associated diarrhoea in children. The evidence for treatment once diarrhoea has started is less robust. Prescribing a probiotic alongside antibiotics is a reasonable clinical decision with a good safety profile.