Pediatric nursing book

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Subject Page No
Overview of pediatric nursing 4
Growth and Development 11
Growth and Development of Newborn 18
Infectious disease of Newborn 44
Growth and Development of Infant stage 63
Growth and development of toddler 76
Growth and development of preschool child 90
Nursery School 96
Growth and development of School Age Children 101
Normal growth and development of adolescence 108
Health Promotion 116
Accident prevention 122
Play 128
Infant Feeding and Weaning 135
Immunization 145
AIDS 157
Hospitalization 162
Nutritional disorders 166
Hematological disorder 184
 Anemia
 Hemophilia
Oncology 200
Communicable Diseases Children in Egypt 211
Respiratory Disorders 241
Parents Reactions toward the Imperfect Child 255
Intestinal Parasites 258
Gastrointestinal Tract 270
Congenital Anomalies 277
Nervous system disorder 287
 Down syndrome
 Autism
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  Attention Deficit Hyperactivity Disorder
 Cerebral palsy
 Mental retardation
Congestive heart failure
309
Rheumatic Fever
315
Nephrotic Syndrome
322
Musculoskeletal system disorders
328
Endocrine Disorders
348

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Overview of pediatric nursing

Prepared by

Dr.Safaa Ramadan

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 Overview of pediatric nursing
Objectives

- Identify the concept of pediatric nursing

- List goals of pediatric nursing
- Describe the qualities of good pediatric nurse
- Describe the roles of the pediatric nurse.
- Trends in pediatric nursing
Introduction: -

Health is a fundamental right of every human being. Health care of

the children has been considered as the vital importance to all societies
because children are the basic resource for the future of humankind and a
healthy child becomes a healthy citizen and a healthy citizen makes a
healthy nation‖. Nursing care of children is concerned for both the health
of the children and for the illness that affect their growth and
development.

Pediatrics can be defined as the branch of medical science that

deals with the care of children from conception to adolescence in health
and illness. It is concerned with preventive, promote, curative and
rehabilitative care of children. Thus, the pediatric nursing involves in
giving assistance, care and support to the growing and developing
children to achieve their individual potential for functioning with fullest
capacity.

The pediatric nurse is one of the important components of the

health team in caring for children. The pediatric nurse gives direct
bedside care to sick children, guide families in their care for their children
during health and illness, in hospitals and at homes.

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Concept of pediatric nursing: -

Pediatric nursing is the specialized area of nursing practice

concerning the care of children during wellness and illness. It includes
preventive, promotive, curative and rehabilitative care of children. It
emphasizes on all around development of body mind and spirit of the
growing individual.

Goals of pediatric nursing

 To provide skillful, intelligent, need based comprehensive care to

the children in health and sickness.
 To interpret the basic needs of the children to their parents and
family members and to guide them in childcare.
 To promote growth and development of children towards optimum
state of health for functioning at the peak of their capacity in
future.
 To prevent disease and alleviate suffering in children.
Qualities of good pediatric nurse: -

 Good observer.
 Honest and truthful.
 Sympathetic, kind, patient and cheerful.
 Well-informed, skillful, and responsible.
 Love to work with children.
 Interested in family care.
 Able to provide teaching to children and their families.
 She should have good judgment and communication ability
based on scientific knowledge and experience.

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Role of Pediatric Nurse (based on primary health care)

The pediatric nurse's role is unique because of developmental

immaturity and vulnerability of children. The goals of nursing care of
children, based on primary health care are :

A. Promote the healthy maturation as a physical, intellectual and

emotional being within the context of his family and communities
(primary level(.

B. Provide health care for the child who requires treatment from
disease(s) (secondary level).

C. Dealing with the child's disabilities (tertiary level).

the role of the pediatric nurse includes :

A.In Primary Level :

Through health education to child and his parents and providing

child's basic needs and immunization, she can :

1. Maintain child's health .

2. Help the child achieves his optimal growth and

development .

3. Prevent diseases and their complications .

B. In Secondary Level :

The nurse has to provide care to sick children and their families by :

1. Assessing their needs .

2. Planning for care .

3. Implementing the plan .

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 4. Evaluating children's condition .

5. Providing heath teaching to children and their parents

C. In Tertiary Level :

The nurse should assist children to return to their maximal level of

functioning following illness and /or disabilities.

Multi-roles of pediatric nurse: -

1. Primary role

 Caregiver: pediatric nurse should provide preventive,

promotive, curative and rehabilitative care in all levels of
health services as therapeutic agent. In hospital, care of sick
children, i.e. comfort, feeding, bathing, safety, monitoring,
administering therapeutic intervention, etc. are the basic
responsibilities of the pediatric nurse. Health assessment,
immunization, primary health care and referral are basic
responsibilities at the community level as quality care
provider.

 Educator: The pediatric nurse can maintain child's health, help

the child to achieve his optimal growth and development and
prevent diseases and their complications through health
education to the child and his parents about healthy lifestyle,
behavior, and attitude to develop healthful practice regarding
child care.

 Advocate: child or family advocacy is basic aspect to

comprehensive family centered care. The pediatric nurse can assist
family and children to make informed decisions and choose

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 appropriate solutions to their problems. Also, attention to patients’
safety and protecting patients from harm.

 Researcher: nursing research is an integral part of professional

nursing. Pediatric nurse should participate or perform research
projects related to child health, include identifying problem areas;
collecting, analyzing and interpreting data, applying findings; and
evaluating, designing and conducting research. Clinical and applied
research provide the basis for changes in nursing practice and
improvements in the health care of children.

 Manager or leader: The pediatric nurse is the manager of pediatric

care units in hospital, clinics and community. She/he should
organize the care orderly for successful outcome with better
prognosis and good health. The manager who plans, gives
direction, developing staff, monitoring operations, giving rewards
fairly and representing both staff member and administration as
needed.

2. Secondary role

 Coordinator and collaborator: pediatric nurse should work together

and in combination with other health team members towards better
child health care. She/he should act as liaison among the members
and maintain good interpersonal relationship. The nurse interprets
the objectives of health care to the family and co-ordinates nursing
services with other services necessary for the child. She/he
collaborates with other health care members, social service
agencies, judicial systems and schools to ensure holistic care.

 Communicator: To care for infants and children, nurse must

communicate effectively with children and their families. Using

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 play and other creative and developmentally appropriate
communication techniques can help nurse in this effort.

 Consultant: The pediatric nurse can act as consultant to guide the

parents and family members for maintenance and promotion of
health and prevention of childhood illness. The nurse can help the
older children to become responsible for their own lives and assist
them in developing the ways of self-care and self responsibility.

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 Growth and Development

Prepared by

Assistant professor Dr. Azza Elewa

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Learning objectives

On completion of this chapter, the student should be able to

Define growth and development.

Identify patterns of growth and development

Mention the principles of growth and development

List factor influences on a child’s growth and development.

Mention types of growth and development

Explain the stages of development

Discuss the role of the nurse in understanding growth anddevelopment.

Growth: is a physical increase in the size of the whole body. It is a

quantitative change in the child’s body and can be measured accurately
by Kg, pounds, meters, inches, …..etc

Development: is the progressive increase in skill and capacity of

function . It is a qualitative change in the child’s functioning andmore
difficult to quantify. It can be observed and cannot be measured. As
children develop their capacity to learn and think.

GrowthPattern

Cephalocaudal pattern:Growth starting from the head and moving

downward (head down to toes). The child is able to control the head,
chest and neck before being able to control the arms and legs.

Proximodistal pattern: growth starts in the center of body and

progresses toward the periphery or outside (growth of the arms & legs
before hands & feet). The child can control movement of the arms

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before being able to control movement of the hands. Another
example of proximodistal growth is the ability to hold something in the
hand before being able to use the fingers to pick up an object.

Cephalocaudal Pattern (head to toe)

Proximodistal Pattern (from center outward)

Principles of Growth & Development

-Growth and development continues from conception through adulthood

-Growth and development gotogether but at different speeds.

They are intimately related, but are not necessarily dependent on one
another.

-Predictable Sequence. Each stage of G&D is affected by the preceding

types of development

-There are periods of time when growth is more rapid than others
and times when development is slowed. Don’t progress at the same
rate (↑ periods of GR in early childhood and adolescents & ↓ periods of
GR in middle childhood)

-Each child grows in his/her own unique way,not every child, follows the
same growth and Development pattern.

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Factors that affect growth and development

1-Genetics

The science of genetics studies the ways in which normal and

abnormal traits are transmitted from one generation to the next. Some
diseases are genetically transmitted. If a child has a genetic
predisposition to a certain disease, that child might not grow and
develop as completely as a healthy child would. Physical and mental
disorders can occur as a result of a child’s genetic factors.

2- Hormones: The principal hormones influencing early growth are

growth hormone and thyroid hormone. Disturbance of any of these
affects a child’s growth.

3-Pre-natal environment

1-Factors related to mothers during pregnancy:

- Nutritional deficiencies

- Diabetic mother

- Exposure to radiation

- Infection with German measles

- Smoking

- Use of drugs

2-Factors related to fetus

• Mal-position in uterus

• Faulty placental implantation

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4-Post-Natal Environment

- Socio-economic status :children and adults from higher socioeconomic

classes are taller than their peers from the lower classes.

- Child’s nutrition: It is important that the child have adequate amounts of

food and nutrients for the body to grow. Malnutrition is still a cause of
poor growth, and is sometimes associated with neglect. Over nutrition, a
leading cause of obesity.

- Illness: Illness causes a child’s growth to slow down. If the illness is

short-lived, rapid catch-up occurs. Chronic illness can irreversibly and
profoundly affect growth.

-Psychosocial factors: An adverse psychosocial environment, particularly

if there is emotional neglect, can have a profound negative effect on a
child’s growth

- Climate and season

- Number of siblings in the family

- Family structure (single parent or extended family … )

Types of growth and development

Types of growth :

- Physical growth (Ht, Wt, head & chest circumference)

- Physiological growth (vital signs)…

Types of development:

- Motor development

- Cognitive development

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- Emotional development

- Social development

Stages of Growth and Development

Prenatal

- Embryonic (conception- 8 w)

- Fetal stage (8-40 or 42 w)

Neonate :Birth to end of 1 month

Infancy: 1month to end of 1 year

Early Childhood

Toddler: 1-3years

Preschool: 3-6 years

Middle Childhood

School age: 6to 12 years

Late Childhood

Adolescent:13 years to approximately 18 years

Theories of Child Development

Freud Psychosexual Development

Infant: Oral stage

Toddlers: Anal Stage .

Preschool: Phallic Stage

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school-age: Latency Stage

Adolescence stage: Pubertal stage

Erikson

Infancy Trust vs mistrust

Toddlerhood Autonomy vs shame and doubt

Preschooler Initiative vs guilt

School-age Industry vs inferiority

Adolescence Identity vs role confusion.

Piaget- Theory of Intellectual Development

Sensoriomotor Thought 0-2 yrs

Preoperational Thought 2-7 yrs

Concrete Operations 7-11 yrs

Formal Operations >11 yrs

Importance of Growth and Development for Nurses:

Knowing what to expect of a particular child at any given age.

Helping in formulating the plan of care.

Helping in parents’ education in order to achieve optimal growth &

development at each stage

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Growth and Development of Newborn

Prepared by

Assistant professor Dr. Azza Elewa

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Outlines

Definition of newborn

Physical growth of newborn .

Physiological growth of newborn

Development of newborn .

Assessment of newborn .

Apgar score .

Physical and general appearance assessment .

Neurological assessment

Sensory assessment

Basic need of newborn

Problem of newborn

Care and nursing intervention for newborn .

Introduction

Care of the newborn infant is a very important part of pediatrics.

Newborn’s ability to adapt successfully depends upon conditions in utero,
care it receives during intrapartum period. Most of deaths that occur in
1st year of life occur during neonatal period [1st 28 days of life].

Definition of neonatal period

Period from birth to 4 weeks postnatal, (neonatal period = 1st 28 days of

life).

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Characteristics of normal Newborn

- Growth measurements

-Vital Signs

- Assessment from head to toe

Growth measurements

Weight: 2.500-4.000 gm.

They lose 5 % to 10 % of weight by 3-4 days after birth as result of :

Withdrawal of hormones obtained from mother.

Passage of meconium (feces) and urine.

Limited food intake.

Length:

Boys average Ht = 50 cm

Girls average Ht = 49 cm

Normal range for both (47.5- 53. 5 cm)

Chest circumference:

It is 30 to 33cm (usually 2–3cm less than head circumference).

Head circumference: 33-35 cm

Vital signs

-Temperature (36.5 to 37.5C)

-Pulse normal rate of hear beat ( 100 to 150 b/min.( it is irregular due to
immaturity of the cardiac regulatory system

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 - Respiration normal rate (35– 50 breaths/minute.), it is irregular in
depth, rate and rhythm.

-Blood pressure 65-85 / 45-55 mmHg .

Head to toe Assessment of newborn

- General appearance:
Posture:
Flexion of extremities, taking them toward chest & abdomen

Head :

Size: ¼ of body size, (Head circumference: 33-35 cm).

Fontanels: “soft spot”

Are opening at point of union of the skull bones or meeting two sutures,
these should be palpate to determine whether they are open or closed.

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*Fontanels should be flat, soft & firm. It bulge when the newborn cries or
if there is increased in ICP.

Anterior fontanel: Is diamond in shape, located between of 2 parietal &

frontal bones. It is 2-3 cm in width & 3-4 cm in length. It closes between
12-18 months of age.

Posterior fontanel: Is triangular in shape, located between the parietal &

occipital bones. It complete closes by the 2- 6 weeks of age.

Two conditions may appear in the head:

Caput succedaneum & Cephalohematoma

Cephalohaematoma: Collection of blood between skull bone &

periosteum (membrane covers the surface of bone).

Caput succedaneum: Swelling of the skull due to pressure during labor

leading to accumulation of fluids and disappear by 3rd day.

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 Difference between a Caput Succedaneum and ephalhematoma

Caput Succedaneum Cephalhematoma

Location Presenting part skull bone & periosteum
of the head
Extent of crosses the suture does not cross the suture
Involvement lines lines
Period of Absorption 3 to 4 days Few weeks to months

Treatment None Supportive

Eyes

Eyes: usually blue or gray, true color is not determined until the
age of 3-6 months. Permanent color develops 6 - 12 months of age.
Absence of tears. Scant discharge .

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- Usually edematous eye lids for two days after birth, until the kidney
eliminate the excess fluid.
- Blinking reflex is present in response to touch

Ears

Ears: Note position of ears in relation to eyes.

Pinna should be fully formed and firm, flexible, cartilage present.

Nose

Nasal Patency, presence of nasal discharge or stuffiness, thin white

mucous.

Mouth & Throat:

- Intact.

-Mouth should be examined for abnormalities such as cleft lip and/or

cleft palate.

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- Evaluate sucking reflex.

-Rooting reflex
- Minimal salivation

Neck:

Normal newborn neck short, thick, usually surrounded by skin folds.

Inspect masses, limitation of movement & webbing

Chest: Inspect shape, symmetry, position, development of nipples; breast

tissue.

Chest circumference ) 30 –33 cm. (

Normal respirations 35 – 50 breaths/minute.

Abdomen

Cylindrical in Shape

palpate for masses.

Normal Umbilical Cord: Inspect 3 vessels 2 arteries & one vein

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(―AVA‖); falls off in 7 – 10 days.

If only 2 vessels present, artery and vein, observe infant closely due to
association with heart or kidney anomalies.

Urinary System:

Normally, the newborn has urine in the bladder and voids at birth or some
hours later. Kidneys felt on right & left side of abdomen by deep
palpation.

Genitalia

- Male

Assess for maturity & sexual abnormality.

Normal length of newborn’s penis = 2cm long.

Urethral opening is at tip of glans penis.

Testes, both right & left testes are palpable in scrotum.

Female:

Labia minora & clitoris with labia majora covering both

-Labia & Clitoris are usually edematous.

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-Urethral meatus is located behind the clitoris.

-Vernix caseosa is present between labia

Female genitalia, normal with vaginal discharge

Breast :
Swollen breasts:

Swollen appears on 3rd day in both sex & lasts for 2-3 weeks and
gradually disappears without treatment.

N.B: The breasts should not be expressed as this may result in infection
or tissue damage.

The breast enlargement almost always disappears during the first few
weeks.

Extremities

Arms and Legs: arms and legs; should be symmetrical, arms and legs
flexed and held close to their bodies. The hands are usually tightly closed
and it may be difficult to open them up.

Fingernails: Infants' fingernails can be long enough at birth to scratch

their skin.

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Back/Anus/Rectum

Spine: Assess for intact spine without masses or openings.

Anus & Rectum: Assess rectal patency with 1st temp; lubricated
thermometer.

If rectum not patent, called imperforate anus.

Skin characteristic

General description:

Color: red or dark pink.

Texture: soft and has good elasticity.

Edema is seen around eye, face, feet and scrotum or labia.

Acrocyanosis:

Bluish discoloration of hands and feet.

Lasts for 24-48 hrs.

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Milia:

Small white pinpoint spots.

They will disappear within 1-2 weeks common on the nose, forehead &
chin of the newborn .

Lanugo: fine hair covering newborn’s upper arms, shoulders & back that
decreases as gestational age increases. Increase in preterm

Vernix Caseosa: white or yellowish cream cheese layer that may thickly
cover the skin of the newborn or it may be found only in the body creases
and between the labia; skin lubricant.

Mongolian spots:

Black coloration on the lower back, buttocks, & around the wrist or
ankle.; usually disappear during preschool years without any treatment.

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Desquamation:

Peeling of the skin

Jaundice: This is a yellow discoloration that may be seen in the

newborn skin or in the sclera of the eye.

- Physiological jaundice .

- Pathological jaundice

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Central Nervous system (Neurologic and sensory assessment :
Reflexes:

Neonatal reflexes or primitive reflexes, should be fully present at birth.

These reflexes are not learned and are involuntary .

Successful use of reflex mechanism is a strong evidence of normal

functioning CNS.

Protective reflexes as:

1. Blinking reflex

2. Coughing and sneezing

3. Gagging.

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 Reflex Stimulation Response Duration

Blinking Flash of light or puff of Closes eyes and open Permanent

air
Grasping Palms touched Grasps tightly Weakens at three
months; disappears at
a year
Moro Sudden move; loud Startles; throws out Disappears at three to
(startle) noise arms and legs and then four months
pulls them toward
body
Stepping Infant held upright with Moves feet as if to Disappears at three to
feet touching ground walk four months
Rooting Cheek stroked or side Turns toward source, Disappears at three to
of mouth touched opens mouth and four months
sucks
Sucking Mouth touched by Sucks on object Disappears at three to
object four months
swallowing Throat muscles close Swallow food Permanent
trachea, open
esophagus when food
in mouth
tonic neck Placed on the back the head is turned to Disappear at 2-3
reflex one side, the arm and months
leg on the same side
will extend, while the
opposite limbs bend.

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 Moro’s reflex

Sucking reflex

Grasping reflex

Gagging reflex.

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Rooting reflex.

tonic neck reflex

Feeding reflexes :

Sucking reflex.

Swallowing reflex.
Gagging reflex

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Newborn Senses

- Touch

It is the most highly developed sense.

Most activities e.g feeding and bathing him, changing clothes and
diapers, holding him stimulate sense of touch and movement.

The newborn is usually comfortable and feel secure with touch

Vision

Pupils react to light

Follow objects in line of vision

Hearing Auditory

The newborn infant usually makes some response to sound from birth.

Listen to the mother voice

The newborn infant responds to sounds with either cry or eye movement.

Smell

At birth, newborn demonstrate that they discriminate odors by turning

away from unpleasant smells.

Newborn quickly learns to recognize familiar smells, can smell breast

milk. .

Taste

Well developed as bitter and sour fluids are resisted, while sweet fluids
are accepted.

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Adaptation to Extra uterine Life

Respiratory adjustment:

Fetal lungs are uninflated because newborn are not needed for
oxygen exchange.

Site of gas exchange: Placenta.

Newborn :Immediately after birth, the newborn’s lungs must inflate,

and gas exchange must begin.

First breath usually taken within 30 second after birth

Site of gas exchang :Lungs

Cardiovascular adjustment:

The transition from fetal to postnatal circulation involves the functional

closure of the fetal shunts: the foramen ovale, the ductus arteriosus.

Thermoregulation

The process by which heat production is balanced with heat loss is called
thermoregulation.

This process is developed poorly in the newborn due to:

Immature hypothalamus

A large surface area to body mass ratio

Lack of subcutaneous fat

Altered blood flow (e.g. peripheral cyanosis)

Poor energy stores and limited fat =

limited thermogenesis (heat production)

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Methods of heat loss:

conduction, convection, radiation, and evaporation

A)Conduction: Heat is lost to a cold surface, such as a cold scale or

board, touching the newborn’s skin.

Prevention:
Warm all objects before the infant comes into contact with them.

(B)Convection: Heat is lost to air currents that flow over the newborn
(e.g., from a fan, air conditioner, or movement around the crib).

Prevention:
· Keep infant out of drafts
· Close one end of heat shield in incubator to reduce velocity of air.

C) Radiation: Heat moves away from the newborn’s body toward a

colder object that is close by, such as a cold window or the sides of the
bed.

(D) Evaporation: Heat is lost along with the moist that evaporates from
the newborn’s wet skin, if newborn is not dried immediately after birth or
if wet clothes or blankets are left next to his skin.

Prevention:
Carefully dry the newborn infant after delivery or after bathing

Urinary System:

Normally, the newborn has urine in the bladder and voids at birth or some
hours later.

Total volume of urine per 24 hours is about 200 to 300 mL by the end of
the first week.

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However, the bladder empties when stretched by a volume of 15 mL,
resulting in as many as 20 voiding per day.

The first voiding should occur within 24 hours. The urine is colorless and
odorless.

There is a functional deficiency in the kidney's ability to concentrate

urine.

The most common cause of failure to void in neonate is dehydration

Gastrointestinal adjustment:

Stomach capacity is limited to about thus, the infant requires frequent

small feedings, limited ability to digest fats & starches.

The colon also has a small volume; the newborn may have a bowel
movement after each feeding.

Newborns who breast-feed usually have more frequent feedings and more
frequent stools than infants who receive formula.

Change in stooling Patterns of Newborns

Meconium

The dark green substance forming the first Feces of a newborn infant. It
composed of amniotic fluid and intestinal secretions, and possibly blood
(ingested maternal blood).

Term healthy neonates pass meconium between 24 to 48 hours following

birth

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Transitional stools

By 2nd - 3rd day, transitional stool passed after initiation of feeding;

greenish brown to yellowish brown, thin and less sticky than meconium.

The liver adjustment:

The liver is also deficient in forming plasma proteins.

The decreased plasma protein concentration probably plays a role in the

edema usually seen at birth.

Prothrombin and other coagulation factors are also low.

The liver stores less glycogen at birth than later in life. Consequently, the
newborn is prone to hypoglycemia, which may be prevented by early and
effective feeding, especially breast-feeding.

Needs of Newborn

1. Clear airway.
2. Established respiration.
3. Maintenance of body temperature.
4. Protection from Hge.

5- Protection from infection

6-love and security (attachment).

7- Nutritional needs

8. Identification

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 Role of the nurses

A-Immediate care

1-Immediate Assessment: it includes the initial assessment APGAR

Component
Score of 0 Score of 1 Score of 2
of acronym

no cyanosis
blue at
blue or pale all body and
Skin color extremities Appearance
over extremities
body pink
pink

< 100 beats > 100 beats per

Pulse rate absent Pulse
per minute minute

grimace on
Reflex irritabi no response to suction or cry on
Grimace
lity grimace stimulation aggressive stimulation
stimulation

flexed arms
Activity none some flexion and legs that Activity
resist extension

Respiratory weak,
absent Strong cry Respiration
effort irregular

Apgar Score: used to assess physical condition at one and five minutes
and is include 5 components (-Heart rate -Respiratory effort -Muscle
tone -Reflex irritability –Color).

-Score of 0, 1, or 2 for each component.

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-Score of 4 or less indication that infant most likely needs resuscitative
efforts

-Score of 4 or less indication that infant most likely needs resuscitative

efforts

-Score of 4-6 may indicate suctioning and oxygen therapy.

2. Maintenance of body temperature.

Newborn Infant should be warmed quickly by wrapping in a warm towel

and Uses extra clothes or blankets to keep warm.

Skin to skin contact to be more effective. If the infant is in incubator,

increase the incubator’s temperature. Avoid exposure to direct source of
air drafts, cover head. Check body temperature frequently

3- Maintain airway clear and established respiration:

suction newborn mouth and nose to remove mucous which may obstruct
airway.

Wipe the mouth with a finger covered with a piece of gauze.

4-Clamping of Cord: After delivery, 2 clamps placed

Cord clamped again 1- 2 inches from umbilicus Vessels counted (2

arteries; 1 vein – AVA).

Bleeding may occur if clamp not tight, umbilical stump; falls off by 7th -
10th day.

5- Eye Care: erythromycin ointment .

6-weighing the newborn

7-Identification of Newborn

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Identification is 1 band on mom & 2 on baby

8-Vitamin K Injection

Newborn at risk for bleeding disorders during 1st wk of life. Injection

given IM within 1st hour.

9- Feeding

In DR, infant given to mother to begin bonding process & breast feeding
started.

10- Immunization

- Hepatitis B

-OPV (0) dose

- BCG

B-Education of parent

Teach parents: sponge bathe before cord falls off and tub bath after cord
falls off & healed.

Hold upright to feed formula & burp.

Teach breast feeding positions.

Routine newborn care

Problem of newborn

Birth injuries

Jaundice

Colic

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Abdominal distention

Vomiting and regurgitation

Infection and fever

Danger signs in the newborn

Respiratory problems, Rapid or difficult of respiration.

Shock

Hyperthermia

Unconscious/ convulsing/spasms

Unable to breastfeed,Poor or absent of sucking

Very or extremely low birth weight.

Appearance of yellow coloration of skin and eyes

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 Infectious diseases of newborn

Objectives

At the end of this lecture the students should be able to:

 Identify different types of neonatal infection.

 Recognize etiology, clinical manifestations, and treatment of
neonatal infection.
 Discuss the nursing role for each type of neonatal infection.

Introduction

The infant's ability to resist infection is limited by its

immature immune system. In addition, the immune system of the neonate
may respond in ways that can create problems that complicate treatment,
such as the release of inflammatory chemicals. Congenital defects of the
immune system also affect the infants ability to fight off the infection.

Some neonatal infections are apparent soon after delivery, while

others may develop in the postnatal period. Some neonatal infections
such as HIV, hepatitis B, and malaria do not become apparent until much
later. There is a higher risk of infection for preterm or low birth
weight neonates. Research to improve treatment of infections and
prophylactic treatment of the mother to avoid infections of the infant is
ongoing.

Neonatal infections are infections of the neonate (newborn)

acquired during prenatal development or in the first four weeks of life
(neonatal period). The causes and reasons for neonatal infection are

44
many. The causative agents of neonatal infection are bacteria, viruses,
and fungi.

Classification of neonatal infection

It classified according to when acquired for 3 types of neonatal

infection

1) In utero infection, which can occur any time before

birth, infections may be contracted by mother to the infant in utero
transplacentally or through ruptured membranes.
Common infectious agents transmitted transplacentally include
rubella, toxoplasma, and syphilis. HIV and hepatitis B are less
commonly transmitted transplacentally. Consequences depend on
the agent and timing of infection in gestation and
include spontaneous abortion, intrauterine growth
restriction, premature birth, stillbirth, congenital malformation
(eg, rubella),

2) Intrapartum infection: Neonatal infections with herpes simplex

viruses, HIV, hepatitis B, group B streptococci, enteric gram-
negative organisms (primarily Escherichia coli), usually occur
from passage through an infected birth canal during delivery
(intrapartum)

3) Postpartum infections are acquired from contact with an infected

mother directly (eg, TB) or through breastfeeding (eg, HIV) or
from contact with family or visitors, health care practitioners, or
the hospital environment.

45
Most common neonatal infection

Ophthalmia neonatorum

Ophthalmia neonatorum (ON), also called neonatal conjunctivitis,

is an acute, mucopurulent infection presents during the first month of
life, affecting 1.6% to 12% of all newborns. Neonatal conjunctivitis is a
form of conjunctivitis and a type of neonatal infection contracted by
newborns during delivery. It may be infectious (bacteria and viruses) or
noninfectious (chemical). Prevention with antigonococcal topical
treatment at birth is routine. Diagnosis is clinical and usually confirmed
by laboratory testing. Treatment is with organism-specific antimicrobials.

Definition

Neonatal conjunctivitis is an inflammatory disease characterized by

watery or purulent ocular drainage due to a chemical irritant or a
pathogenic organism.

Etiology

The three main etiologies of neonatal conjunctivitis include:

a) Chemical

b) Bacterial (C. trachomatis most common)

c) Viral

a) Chemical or Noninfectious

Chemical conjunctivitis accounts for most cases of ON, presenting

as a mild, purulent conjunctivitis within the first 24 hours of life. It
is most commonly associated with silver nitrate prophylaxis, or
secondary to prophylaxis with other agents such as erythromycin or

46
 tetracycline. Chemical conjunctivitis is a self-limiting condition
that does not require any diagnostic tests or treatment.

b) Bacterial: The two most common causes are Neisseria

gonorrhoeae and Chlamydia trachomatis; the organism is
transmitted from the genital tract of an infected mother during birth
or by infected hands.

c) Viral
o Adenovirus

o Herpes simplex virus

Signs and symptoms

 erythema or redness

 discharge (may be profuse in gonococcal infection)

 Lids edema or swelling of eyelids

 cornea can be involved, especially in N.

gonorrhoeae infection. This organism can pass through intact
corneal epithelium and perforation may result

 signs and symptoms usually bilateral

47
Complications

Complications to the newborn from ON can include corneal

scarring, ocular perforation, and blindness

Prevention

Prophylaxis needs antenatal, natal, and postnatal care.

 Antenatal care: Prenatal maternal screening and treatment for

genital infections is the best method of prevention of this condition

 Natal measures are of utmost importance, as most infection occurs

during childbirth. Deliveries should be conducted under hygienic
conditions taking all aseptic measures. The newborn baby's closed
lids should be thoroughly cleansed and dried.

 Postnatal care:
o Ocular prophylaxis: erythromycin and iodopovidone are more
effective than silver nitrate in preventing ophthalmia
neonatorum caused by gonococci and chlamydia. Routine use
povidone iodine 2.5% drops into each eye after delivery
effectively prevents chlamydia and gonococci.
o Neonates of mothers with untreated gonorrhea should receive
a single injection of ceftriaxone 25 to 50 mg/kg IM or IV, up
to 125 mg, and both mother and neonate should be screened
for chlamydia infection, HIV, and syphilis.
Medical Management

Systemic, topical, or combined antimicrobial therapy

 Chemical ophthalmia neonatorum is a self-limiting condition and

does not require any treatment.

48
  In chlamydial ophthalmia, systemic therapy is the treatment of choice,
because at least half of affected neonates also have nasopharyngeal
infection and some develop chlamydial pneumonia. Erythromycin or
azithromycin is recommended. Topical therapy is not effective and
also does not treat the infection of the nasopharynx.

 Gonococcal ophthalmia neonatorum needs prompt treatment to

prevent complications. A neonate with gonococcal ophthalmia is
hospitalized for evaluation of possible systemic gonococcal infection
therapy should include:

- Saline lavage hourly till the discharge is eliminated

- Bacitracin eye ointment
- Systemic therapy: Newborns with gonococcal ophthalmia
neonatorum should be treated with ceftriaxone, cefotaxime, or
crystalline benzyl penicillin.

 Other bacterial ophthalmia neonatorum should be treated by

broad-spectrum antibiotics drops and ointment.

 Herpes simplex conjunctivitis should be treated with

intravenous acyclovir for a minimum of 14 days to prevent
systemic infection.

 If the cause is determined to be due to a blocked tear duct, a

gentle palpation between the eye and the nasal cavity may be
used to clear the tear duct. If the tear duct is not cleared by the
time the newborn is 1 year old, surgery may be required.

Prognosis

Prognosis of neonatal conjunctivitis is generally considered to be

good as long as early diagnosis is made and prompt medical therapy is

49
initiated. Most cases of infectious conjunctivitis respond to appropriate
treatment. However, morbidity and mortality increase in cases of
systemic involvement requiring hospitalization and intensive monitoring.

Nursing care

 Avoid cross contamination by frequent hand washing and wearing

gloves

 Irrigate eye with sterile isotonic saline

 Provide systemic treatment that required for staphylococcal,

gonococcal, Chlamydia, Pseudomonas and herpetic conjunctivitis

 Avoid eye patching

 Consider Pediatric infectious disease and/or

Pediatric Ophthalmology consult

 Chemical conjunctivitis usually resolves with 24 to 72 hours

Oral moniliasis

Oral candidiasis, commonly known as oral thrush, it is the most

common oral fungal infection in infants and children. It is not usually
serious, but it can be uncomfortable, and it may cause difficulties with
feeding.

A small amount of the Candida fungus lives in the mouth most of

the time. It is usually kept in check by the immune system and other types
of germs that also normally live in the mouth. However, when the
immune system is weaker, the fungus can grow, leading to sores and
lesions in the mouth and on the tongue.

51
 Oral thrush may occur in newborn because their immune systems
have not yet matured. They are less able to resist infection. Also, it
appears infrequently in older children as an adverse effect of antibiotics
or inhaled or topically applied corticosteroids.

Definition

Oral candidiasis is a superficial mucous membrane infection

usually caused by the yeast Candida albicans. It is the most common
oral fungal infection in infants.

Causes

It is caused by a yeast like fungus, Candida albicans.

 normal newborns acquire Candida albicans from their mothers at

delivery through the infected birth canal, and postnatal from
improper sterilization of nipples or unclean hands, pacifier, and
breast of the mother.

 An oral thrush infection can happen after treatment with antibiotics,

because antibiotics reduce the levels of healthy bacteria in the
mouth. This allows fungus to proliferate.

Clinical manifestation

It can appear suddenly and may include:

 white patches on the roof of the mouth, inside the cheeks, and on
the tongue

 patches of white that look like milk, but they cannot be wiped away

 under the white lesions, there may be red tissue that bleeds easily

 there may be redness around the patches

51
  the patches may be painful

 the corners of the mouth may crack

 difficulty of feeding or refusing the breast

Prevention

o Antenatal care: a woman develops a vaginal yeast infection during

pregnancy, she should consult a doctor. If it does not go away, it
may be passed to the newborn during delivery. Symptoms include
vaginal itching and a cheesy white discharge.

o Women who have nipple discharge or pain during breastfeeding

should also notify their health provider, so they can be examined
for a yeast infection in the nipples.

o Ensure that bottle nipples and pacifiers, if used, are sterile. Some
studies have found that Candida is prevalent on pacifiers,

especially latex pacifiers.

52
 o If the infant is breastfeeding, the mother's nipples may need to be
treated at the same time, to prevent the infection passing back and
forth.

Treatment

Some cases go away without medical treatment within a week or

two, but the doctor may prescribe an antifungal solution for baby's mouth
as mycostatin drops (nystatin). This medicine is usually applied several
times a day by "painting" it on the inside of the mouth and tongue with a
sponge applicator.

Nursing care

1- Each infant should have his own feeding equipment.

2- Cleaning of all feeding articles.

3- Mouth care after feeding.

4- Inspection of the infant's mouth whose receiving antibiotic therapy

at least once daily.

Impetigo

Impetigo is a highly contagious bacterial skin infection that

generally isn’t serious. It is observed most frequently in children ages two
to five years, although older children and adults may also be affected. It
clears up faster with antibiotics and requires good hygiene to prevent it
from spreading. It may be classified as primary impetigo (direct bacterial
invasion of healthy skin) or secondary impetigo when it occurs in broken
skin (infection at sites of minor skin trauma such as abrasions, minor
trauma, and insect bites)

53
 An estimated 162 million children worldwide have impetigo.
Impetigo is more common in developing countries and in poor areas of
industrial countries.

Definition

Impetigo is a common and contagious skin infection. Bacteria

infect the outer layers of skin, called the epidermis. The face, arms, and
legs are most often affected.

Causes

Impetigo is an infection caused by bacteria

(Staphylococcus or Streptococcus) entering body through a break in the
skin from a cut, scratch, insect bite, or rash. Then they can invade and
colonize. The condition can be contagious. The child catches these
bacteria if touch the sores of a person with impetigo or touch items like
towels, clothes, or sheets that the person used.

Types of impetigo

There are three types of impetigo based on the bacteria that cause
them and the sores they form. Each type goes through a series of stages.

1) Non-bullous

Non-bullous impetigo is mainly caused by Staphylococcus

aureus. It’s the most common form of impetigo, causing an estimated 70
percent of cases.

It goes through the following stages:

 It usually starts with reddish, itchy sores around the mouth and
nose.

54
  The sores break open, leaving red and irritated skin around them.

 A brownish-yellow crust forms.

 Once the crusts heal, there is no scar left behind.

2) Bullous

Bullous impetigo is almost always caused by Staphylococcus

aureus bacteria.

 It usually forms larger blisters or bullae filled with a clear fluid that
may become darker and cloudy. The blisters start on unbroken skin
and aren’t surrounded by reddish areas.

 the trunk is more frequently affected

 The blisters become limp and clear, and then burst open.

 A yellowish, crusty sore forms over the area where the blisters
broke open.

 The blisters usually leave no scars behind when they heal.

 Fever and swollen lymph glands in the neck are more likely to
occur in Bullous Impetigo. In addition, the scabs take longer to
heal.

55
3) Ecthyma

This more serious infection is much less common. It occasionally

happens when impetigo isn’t treated. Ecthyma goes deeper into the skin
than the other forms of impetigo, and it’s more severe.

 The infection forms painful blisters on the skin of the buttocks,

thighs, legs, ankles, and feet.

 The blisters turn into pus-filled sores with a thicker crust.

 Often, the skin around the sores turns red.

 Ecthyma sores heal slowly and may leave scars after they heal.

Ecthyma

56
Prevention of impetigo:

Children with impetigo should stay home until they are no longer
contagious if the lesions can’t be reliably covered.

Good hygiene is the no. 1 way to prevent impetigo. Follow these tips:

 Bathe and wash your hands often to cut down on skin bacteria.

 Cover any skin wounds or insect bites to protect the area.

 Keep your nails clipped and clean.

 Don’t touch or scratch open sores. This will spread the infection.

 Wash everything that comes into contact with the impetigo sores in
hot water and laundry bleach.

 Change bed linens, towels, and clothing that come in contact with
the sores often, until the sores are no longer contagious.

 Clean and disinfect surfaces, equipment, and toys that may have
come in contact with impetigo.

 Don’t share any personal items with someone who has impetigo.

Complications

Although impetigo is usually a minor infection that can be easily

treated, it

isn't dangerous. Rarely, complications of impetigo include:

 Cellulitis: This potentially serious infection affects the tissues

underlying skin and eventually may spread to your lymph nodes
and bloodstream. Untreated cellulitis can quickly become life-
threatening.

57
  Kidney problems (inflammation).

 Meningitis

 Scarring: The ulcers associated with ecthyma can leave scars.

Medication therapy

a- Apply topical antibiotic oientment such as neosporin and bacitracin

b- Systematic antibiotic as Duricef or erythromycin

Nursing role

 Soak crusts in warm water.

 Gently wash the area with antibacterial soap and remove crusts.

 Apply antibiotic ointment after washing the skin 3–4 times daily.
Wash hands after application or wear gloves to apply.

 Wash clothing, towels, and bedding daily, and don't share these
personal items with others.

 Wash hands frequently, and keep fingernails cut to prevent spread

of infection.

 Provide health education to the child's family about prevention

spread of infection and treatment.

Umbilical infection

The umbilical cord carries nutrients and blood from mother to baby
during pregnancy. After birth, the cord is clamped (to stop bleeding) and
cut close to the navel, leaving a stub. The stub generally falls off in one to
three weeks after birth. During birth and the clamping and cutting
process, germs can invade the cord and cause infection. Infection of the
umbilical cord stump is called omphalitis.
58
 Omphalitis of newborn is the medical term for inflammation of
the umbilical cord stump in the neonatal newborn period, most commonly
attributed to a bacterial infection. It remains a common cause of neonatal
mortality in less developed areas. It is predominantly a disease of the
neonate. Omphalitis can quickly progress to sepsis and presents a
potentially life-threatening infection.

Definition

Omphalitis is an infection of the umbilical stump. It typically

presents as a superficial cellulitis that can spread to involve the entire
abdominal wall and may progress to necrotizing fasciitis, myonecrosis, or
systemic disease.

Causes

Omphalitis is most commonly caused by bacteria as Staphylococcus

aureus, Streptococcus, and Escherichia coli.

Risk factors

Risk factors for omphalitis included:

o septic delivery,

o unplanned home delivery

o maternal chorioamnionitis

o prolonged rupture of membranes

o low birth weight

o umbilical vessel catheterization.

59
Signs and symptoms

 red, swollen, warm, or tender skin around the cord

 pus (a yellow-greenish liquid) oozing from the umbilical stump

 a bad smell coming from the cord

 fever

 a fussy, uncomfortable, or very sleepy baby

 Poor feeding

 yellow skin (jaundice).

 Lethargy

 Floppy, poor muscle tone

Nursing care

1. Check umbilical clamp placement for tight closure. There should

be no bleeding from the cord.

2. Keep cord dry and exposed to the air.

61
 3. Using an alcohol wipe, start from the base of the cord and gently
wipe upward and outward. Cleansing is done at every diaper
change until the cord stump falls off.

4. Observe cord and abdominal area for redness, discharge, or foul

odor.

5. Diaper infant, and be certain the upper end of diaper is folded

down below the cord so it does not rub against the cord.

6. Document cord care and observations, solutions used to cleanse the

area, condition of the cord, teaching of the parents, and their
response.

7. The nurse learns the parents how to fold the diaper below the level
of the umbilicus so that it will not become wet with urine.

General nursing care and measures to protect the newborn

from infection

o Antenatal care: antenatal measures include thorough care of mother

and treatment of infections when suspected.

o Natal measures: deliveries should be conducted under hygienic

conditions taking all aseptic measures.

o Always comply with standard precautions and use transmission-based

precautions

o Hand hygiene before and after contact with each infant is essential to
avoid cross-contamination. Care providers who have direct contact
with the newborn should be required to perform a 3-minute (up to the
elbows) scrub at the beginning of each shift.

61
o Not sharing equipment and supplies between infants. Means every
newborn should have his or her own individual bassinet and supplies.

o Preventing the acquisition of infection from contaminated feedings,

water, or air

o Protecting the infant from infected health care workers and visitors

o Screen visitors and exclude for signs of infection- fever, respiratory

infection, diarrhea, and draining skin infection

o Using invasive medical devices judiciously

o Strictly adhering to aseptic techniques

o Perform recommended cord care. The umbilical cord area and any
broken skin should be assessed daily for redness, warmth, or purulent
discharge.

o If the mother has an infection, the nurse should consult with the health
care provider to determine safety of mother-newborn contact.

o Keep the mother separated from the baby when the mother has TB .

o Encourage exclusive breastfeeding.

o Manage expressing and storage of breast milk carefully to prevent

infection

o Manage the preparation of formula feeds

62
Growth and Development of Infant stage

Prepared by

Assistant professor Dr. Azza Elewa

63
 Growth and Development of Infant stage

It is the period which starts at the end of the first month up to the end of
the first year of age. During this year, the infant grows and develops
skills more rapidly.

The normal growth and development of infant

Physical growth

-Weight: Infant will double birth weight by the age of 6 months, and will
triple his/her birth weight by the age 1 year old.

The infant gains:

 Birth to 4 months → ¾ kg /month

 5to 8 months → ½ kg / month

 9 to 12 months → ¼ kg /month

Calculating infant’s weight

Weight = Age in months + 9

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Wt of 7 months old infant = 7+9 = 16 = 8 kg

2 2

Length: infant will increases about 2.5 cm per month during the first 6
months and 1 ½ cm per month at 7 – 12 months. This increase occurs
mainly in the trunk, rather than in the legs.

Head size:

-At birth, an infant’s head circumference averages about (33-35 cm)

and is usually slightly larger than the chest circumference.

-During the first 6 months head circumference increases approximately

1.5 cm per month and increase 0.5 cm monthly during the second 6
months.

-The average size is 43 cm at 6 months and 46 cm at 12 months.

-Posterior fontanel closes by 6-8 w of age.

-Anterior fontanel closes by 12-18 months of age

Chest circumference

The chest also grows rapidly, and equals the head circumference by the
end of the first year.

Physiological growth of infants-:

Pulse 110-150 b/min

Resp 35 ± 10 c/min

Blood pressure 80/50 ± 20/10 mmHg

65
Dentition:
Eruption of teeth starts by 6–8 months of age. It is called "Milky teeth" or
Deciduous teeth" or "Temporary teeth".

Average age for teeth eruption:

Lower central incisors Erupt at 6 months

Upper central incisors Erupt at 8 months

Upper lateral incisors Erupt at 9 months

Lower lateral incisors Erupt at 11 months

Lower first molars Erupt at 12 months

Upper first molars Erupt at 14 months

Lower cuspids Erupt at 16 months

Upper cuspids Erupt at 18 months

Lower 2nd molars Erupt at 20months

Upper 2nd molars Erupt at 24 months.

66
Locomotion (motor growth) ( gross and fine)

At 2 months

Gross : Hold head erects in mid-position position

Turn from side back

Fine : Hold a rattle le briefly when placed in his hand

At 4 months:

Gross :Sit with adequate support.

Roll over from front to back.

Good head control

Fine : Objects will be involuntarily grasped and dropped without notice.

Plays with fingers, carry object to mouth.

67
At 6 months:

Gross :Lift chest and upper abdomen when prone.

Fine : Hold own bottle. Transfer object from one hand to other

At 8 months:

Gross:

Site alone .

Pull himself to standing position with assistance.

Fine:

Drink from cup with assistance.

Eat finger food that can be held in one hand.

68
At 9 months:

Gross Raises to a sitting position alone

Crawl .

Fine : hold bottle with good hand mouth coordination

At 10 months, the infant can:

Gross

Creep well (use hands and legs).

Fine : can grasp small objects using thumb and forefinger.

69
At 11 months:

Gross:

Walk holding on furniture.

Stand erect with minimal support

Fine:

take toys and put it inside cup or box

At 12 months:

Gross : Stand alone for variable length of time.

Site down from standing position alone.

Walk in few steps with help or alone

Fine:

Pick up small bits of food and transfers them to his mouth

Emotional development

Infant emotions are unstable, where it is rapidly changes from crying to

laugh.Express felling through crying and laugh

By 10 months: can express recognizable emotions, such as anger,

sadness, pleasure, jealousy and affection .

71
Social development

He learns that crying brings attention.

The infant smiles in response to smile of others.

The infant shows fear of stranger (stranger anxiety).

He responds socially to his name.

Psychosocial development (Erikson)

Developing a Sense (Trust vs. mistrust) from birth to 1 year .

-the infant develops sense of trust through interaction with caregiver

(mainly the mother), learns to trust others through the relief of basic
needs as feeding, comfort, stimulation.

Infant whose needs are consistently unmet will develop a sense of

mistrust. Failure to learn "delayed gratification" leads to mistrust.
Mistrust can result either from too much or too little frustration.

Cognitive development (Piaget(

Sensorimotor stage from birth to 2 years, Coordinates sensory

experiences with physical action,

Follows an objects with eyes, recognizes familiar faces, turn head to

locate sound, can fixate on small objects. Adjust posture to see.

Infants learn to separate themselves from other objects in the

environment. Respond to name.

They learn that parts of the body are useful; for example, the hands bring
objects to the mouth and the legs help them move to different locations.

71
Searches for hidden toy.

Language Development (Speech Milestones)

1-2 months: make sounds such as ah, eh, and uh .

2-6 months : laughs

8months : babbles sounds as ma ma, da da.

9 to 10 months

they comprehend the meaning of the word "no" and obey

simplecommands

1 year: they can say three to five words with meaning

Psychosexual development (Freud)
According to Freud oral stage start from birth to 18 months
During this stage, the mouth is the pleasure center for development. Freud
believed this is why infants are born with a sucking reflex and desire their
mother's breast. If a child's oral needs are not met during infancy, he or she may
develop negative habits such as nail biting or thumb sucking to meet this basic
need.
Infant needs
Love and security
Feeding
Warmth and comfortable
Pleasure of sucking
Sensory stimulation

72
Daily care of infant

Infants are small, helpless, and need their parents or caregivers to take
care of them. They need a lot of attention. Sometimes, providing that care
as a new parent or caregiver can seem daunting.

Cleaning baby's face and head

Eye

With clean hands, moisten a cotton ball with warm water and gently clean
infant’s eyelids, wiping from inner eye to outer eye. Use a different piece
of cotton for each eye.

Ears

Use a cotton ball to wipe behind and around the outside of baby’s ears.
Be careful not to stick anything inside baby’s ear this can cause damage.

Hair

Washing baby’s hair and dry it by the towel back and forward across the
scalp.

Oral and teeth care

Clean baby’s gums and tongue using water and a washcloth after morning
and evening feeds.

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Wipe front and back of teeth using water and a clean washcloth. At 12
months use a soft infant toothbrush to brush teeth with water at least
twice a day.

Nail care

Use special baby nail scissors; Work with someone else if it helps one
holds the infant as the other trims the nails. Try trimming baby’s nails
when he’s asleep, in the highchair or while singing a favorite song.

Bathing

The purpose of bath is not only cleanliness but also to Provide

opportunity to note his growth and development, to promote comfort of
the infant, To stimulate circulation. A gentle bath at night before bed may
help an infant relax and sleep better.

Diaper care

Each baby should have about 8-10 wet and/or dirty diapers a day through
the first six weeks of life. After about six to eight weeks see this decrease
to between 4-6 wet diapers a day, and some baby's may only have a
bowel movement once every week or two .
Lift the infant up by the ankles in order to expose the buttocks, washing
and rinsing the buttocks, dry it and apply ointment to the anal area. And
apply the clean diaper

Feeding

Infants grow very quickly and have a need to consume milk, either from a
breast or bottle, to help support and sustain that growth. Breast milk or
formula is a choice each parent should make before a newborn arrives so
they can be prepared with the appropriate knowledge and equipment that

74
will be needed to feed a infant. Most babies need to be fed about every 2-
4 hours because they have small stomachs

Bonding

Infant massage and skin to skin time are important bonding times when
caring for an infant to make baby feel safe, secure and loved, so take
some time out of the day to rub baby down with lotion or hold him/her up

Sleep

The total daily sleep is approximately 15 hours. The number of naps per
day varies, infants may take one or two naps by the end of the first year.
Uncomfortable wetness or dirty diapers can also wake a baby.

Signs of Possible Developmental Delays

Poor sucking reflex, Absent or minimal blink reflex to bright light.

Doesn’t focus and follow a nearby object that is moving side to side.

Moves arms and legs minimally and infrequently; appears stiff.

Response to loud sounds is absent or minimal.

Unable to sit alone by age 9 months, Unable to walk alone by 18 months

Unable to transfer objects from hand to hand by age 1 year

75
 Growth and Development of Toddlers
Objectives:

At the end of this lecture the students will be able to: -

 Identify the toddler period.

 Describe growth and development milestones of toddler child.

 Summarize characteristics and needs of toddler children

 Discuss promoting optimal health during toddlerhood

Toddler stage is a period between 1 to 3 years of age. During this period,

growth slows considerably.

It is the beginning of independence or autonomy. It is a time of

intense exploration of the environment as the child attempts to find out
how things work.

Physical growth

Weight:

 The toddler's average weight gain is 1.8 to 2.7 kg/year.

 Formula to calculate normal weight of children over 1 year of age

is

Age in years X 2+8 = ….. kg.

e.g., The weight of a child aging 3 years = 3 X 2 + 8 = 14 kg

 Triple birth weight at the end age of one year.

Height:

• The child's height increases by 1cm/month.

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 • The toddler's height increases about 10 to 12.5cm/year.

• Formula to calculate normal height of children over 1 year of age

Age in years x 5 + 80 =… Kg

e.g., the length of 2 years old child = 2 X 5 + 80 = 90cm

Head and chest circumference:

• Head increases about 2 cm during the 2nd year compared to 12 cm

during the 1st year.

• From one year to adult head increases 10 cm only.

• Anterior fontanel closes between 12 – 18 months of age.

• Head circumference equal chest circumference at one years of age

• During toddler years, chest circumference continues to increase in

size and exceeds head circumference.

Teething:

• By 2 years of age, the toddler has 16 temporary teeth.

• By the age of 30 months (2.5 years), the toddler has 20 teeth

Abdomen:

• It is protruded and toddler appears " pot – bellied.

• Because their abdominal muscles are not yet strong enough to

support abdominal contents as well as they will later

Physiological growth

 Pulse: 80–130 beats/min (average 110/min).

 Respiration: 20–30C/min.

 Blood Pressure: 99/64 mm Hg

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 Bowel and bladder control:

• The average healthy, intelligent child usually accomplishes bowel

control by the end of the (12-18) month.
• Daytime bladder control may be fairly well established by 24 and
30 months of age, and night control by 3 or 4 years.
Senses:

well developed.

Motor Development

Fine Motor

• 1 year old: transfer objects from hand to hand

• 2 year old: can hold a crayon and color vertical strokes
 Turn the page of a book
 Build a tower of six blocks
• 3 year old: copy a circle and a cross
– build using small blocks

Gross Motor

At 15 months, the toddler can:

• Walk alone.
• Creep upstairs.
• Assume standing position without falling.
• Hold a cup with all fingers grasped around it.
At 18 months:
• Hold cup with both hands.

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 • Transfer objects hand-to hand at will.
At 24 months:
• Go up and down stairs alone with two feet on each step.
• Hold a cup with one hand.
• Remove most of own clothes.
• Drink well from a small glass held in one hand.
At 30 months: the toddler can:
• Jump with both feet.
• Jump from chair or step.
• Walk up and downstairs, one foot on a step.
• Drink without assistance.
Psycho sexual development: -

According to freud's theory of psychosexual development the

toddler is in the anal stage. Pleasure sensation is focused on bowel
movement (withholding/eliminating faces)

Emotional development

• Strong expression of emotions and self-control separates from

parent /caregiver

• Stranger anxiety – should dissipate by age 2 ½ to 3 years

• Temper tantrums: occur weekly in 50 to 80% of children – peak

incidence 18 months – most disappear by age 3 years.

• Sibling rivalry: aggressive behavior towards new infant: peak

between 1 to 2 years but may be prolonged indefinitely

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Cognitive development

• Up to 2 years, the toddler uses his senses and motor development

to different self from objects.

• According to Piaget, the period from 12 to 24 months old is the

sensorimotor phase. During this time, the cognitive processes
develop. The toddler uses his senses and motor development to
differentiate self from objects. The toddler from 2 to 3 years is in
the pre-conceptual phase of cognitive development, where he is
still egocentric and cannot take the point of view of other people.
Preoperational thinking implies that children cannot think in terms
of operations—the ability to manipulate objects in relation to each
other in a logical fashion.

Language Development

 Learning to talk takes a long time.

 From the newborn’s cry to the first spoken word is the change from
a reflex that has a meaning for both the child and others.

 Between the age of one and three years the child is increasingly
able to understand others and to express his feeling and ideas in
word.

 15th months: Says 4 to 6 words (mainly names).

 30th months: Talks constantly, and gives first and last name,
vocabulary of almost 300 words.

Social development

• For toddler, play is the major socializing medium.

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 • Play during toddler age, is typically parallel beside rather than
with another child.

• The toddler is very social being but still egocentric.

• He imitates parents.

• Notice sex differences and know own sex.

• According to Erickson's theory of psychosocial development the

toddler develops sense of autonomy Vs. shame or doubt, the
development of autonomy during this period is centered around
toddlers increasing abilities to control their bodies, themselves and
their environment

Personality traits of toddler

characteristics of the toddler are:

 Ritualistic behavior: The ritualism of this age also dictates certain

principles in feeding practices. Toddlers like to have the same dish,
cup, or spoon every time they eat. They may reject a favorite food
simply because it is served in a different dish.

 Slowness in carrying out requests

 Temper tantrums

Toddlers may assert their independence by violently objecting to

discipline. They may lie down on the floor, kick their feet, and
scream at the top of their lungs. Some have learned the
effectiveness of holding their breath until the parent relents.
Tantrums are an indication of the child's inability to control
emotions; toddlers are particularly prone to tantrums because their
strong drive for mastery and autonomy is frustrated by adult

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figures or lack of motor and cognitive skills. The best approach
toward tapering temper tantrums requires consistency and
developmentally appropriate expectations and rewards. For
example, a popular time for a tantrum is before bed. Active
toddlers often have trouble slowing down and, when placed in bed,
resist staying there. Parents can reinforce consistency and
expectations by stating, ―After this story, it is bedtime.‖

During tantrums, stay calm and ignore the behavior, provided the
behavior is not injurious to the child, such as violently banging the
head on the floor. Continue to be present to provide a feeling of
control and security to the child when the tantrum has subsided.
During periods of no tantrums, practice developmentally
appropriate positive reinforcement. Other suggestions for
preventing tantrums include the following:

• Offer the child options instead of an ―all or none‖ position.

• Set clear boundaries and expectations with all caregivers.

• Ensure a consistent response to child's behavior by all

caregivers.

• Praise the child for positive behavior when he or she is not

having a tantrum or provide a reward system (i.e., sticker chart).

Temper tantrums are common during the toddler years and

essentially represent normal developmental behaviors. However,
temper tantrums can be signs of serious problems. Temper
tantrums that occur past 5 years old, last longer than 15 minutes, or
occur more than five times a day are considered abnormal and may
indicate a serious problem

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 Jealousy and Sibling rivalry

The term sibling rivalry refers to a natural jealousy and resentment

toward a new child in the family or toward other children in the
family when a parent turns his or her attention from them and
interacts with their brother or sister.

The arrival of a new infant represents a crisis for even the

best-prepared toddlers. They do not hate or resent the infant; rather,
they hate the changes that this additional sibling produces,
especially the separation from mother during the birth. The parents
now share their love and attention with someone else, the usual
routine is disrupted, and toddlers may lose their crib or room

Preparation of children for the birth of a sibling

 A good time to start talking about the baby is when toddlers

become aware of the pregnancy
 parents should perform anticipated changes, such as moving the
toddler to a different room or bed
 Telling them that a new playmate will come home
 parents should stress the activities that will take place when the
baby arrives home, such as diapering, bottle feeding or
breastfeeding, bathing, and dressing. At the same time, parents
should emphasize which routines will stay the same, such as
reading stories or going to the park.
 Providing a doll with which toddlers can imitate parental
behaviors is another excellent strategy. They can tend to the
doll's needs (diapering, feeding) at the same time the parent is
performing similar activities for the infant.

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 Negativism:

One of the more difficult aspects of rearing children in this age

group is their persistent negative response to every request. The
negativism is not an expression of being stubborn or insolent but a
necessary assertion of self-control. One method of dealing with the
negativism is to reduce the opportunities for a ―no‖ answer. Asking
the child, ―Do you want to go to sleep now?‖ is an example of a
question that will almost certainly be answered with an emphatic
―no.‖ Instead, tell the child that it is time to go to sleep and proceed
accordingly. In their attempt to exert control, children like to make
choices. they are more likely to choose one rather than
automatically say no.

 Regression

The retreat from one's present pattern of functioning to past levels

of behavior is referred to as regression. It usually occurs in
instances of discomfort or stress. Regression is common in toddlers
because almost any additional stress hinders their ability to master
present developmental tasks. Any threat to their autonomy, such as
illness, hospitalization, separation, disruption of established
routines, or adjustment to a new sibling, represents a need to revert
to earlier forms of behavior, such as increased dependency. This
can include refusal to use the potty chair; temper tantrums; demand
for the bottle or pacifier; and loss of newly learned motor,
language, social, and cognitive skills.

When regression does occur, the best approach is to ignore it

while praising existing patterns of appropriate behavior.
Regression is a child's way of saying, ―I can't cope with this

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 present stress and perfect this skill as well, but I will eventually if
given patience and understanding.‖ For this reason, it is advisable
not to attempt new areas of learning when an additional crisis is
present or expected, such as beginning toilet training shortly before
a sibling is born or during a brief period of hospitalization.

Needs of toddler

1. Love and security: feels secure in his/her parents' affectionate care of

him.

2. Graded independence: Independence in self-care learned gradually,

give the child one situation in which he can guard him from physical
and emotional trauma.

3. Elimination control or control of bodily functions:

§ Toilet training is one of the major tasks of toddlerhood. It should be

started when the toddler is physiologically and psychologically
ready.
§ He is physiologically ready when he can stand-alone.
Provide information, guidance, and support to parents for managing
this potentially frustrating process. Voluntary control of the anal
and urethral sphincters is achieved sometime after the child is
walking, probably between 18 and 24 months old. Trends in toilet
training have changed, likely due to the availability of disposable
diapers. In the 1920s, toilet training began around 12 months old,
which changed to at least 18 months old in the 1960s, and is now
initiated around 21 months old with approximately half of children
toilet trained by 36 months old. Bowel training is usually
accomplished before bladder training because the sensation for
defecation is stronger than that for urination and easier for children
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 to recognize. An important role for the nurse is to help parents
identify the readiness signs in their children
Four markers signal a child's readiness to toilet train:

(1) waking up dry from a nap or overnight sleep

(2) being aware of the urge to void or stool

(3) communicating the need to go

(4) being dry for at least 2 hours during the day.

Promoting Optimal Health during Toddlerhood

Understanding toddlers is fundamental to successful childrearing.

Nurses, particularly those in ambulatory or child health centers, are in a
favorable position to assist parents in facilitating the tasks and meeting
the needs of children in this age group.

Parents’ guidance during the toddler years includes:

12 to 18 Months Old

 Prepare parents for expected behavioral changes of toddlers,

especially negativism and ritualism.

 Assess present feeding habits and encourage gradual weaning from

bottle and increased intake of solid foods.

 Stress expected feeding changes of physiologic anorexia, food fads

and strong taste preferences, need for scheduled routine at
mealtimes, inability to sit through an entire meal, and lack of table
manners.

 Assess sleep patterns at night, particularly habit of a bedtime

bottle, which is a major cause of early childhood caries (ECC). The

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 toddlers sleep on the average 12-14 hours out of 24 hours including
a day time nap of one to two hours.

 Prepare parents for potential dangers of the home and motor

vehicle environment, particularly motor vehicle injuries, drowning,
accidental poisoning, and falling injuries; give appropriate
suggestions for childproofing the home.

 Discuss need for firm but gentle discipline and ways to deal with
negativism and temper tantrums; stress positive benefits of
appropriate discipline.

 Emphasize importance for both child and parents of brief, periodic

separations.

 Discuss toys that use developing gross and fine motor, language,
cognitive, and social skills.

 Emphasize need for dental supervision, types of basic dental

hygiene at home, and food habits that predispose to caries; stress
importance of supplemental fluoride.

18 to 24 Months Old

 Stress importance of peer companionship in play.

 Explore need for preparation for additional sibling; stress

importance of preparing child for new experiences.

 Discuss present discipline methods, their effectiveness, and parents'

feelings about child's negativism; stress that negativism is
important aspect of developing self-assertion and independence
and is not a sign of spoiling.

 Discuss signs of readiness for toilet training; emphasize importance

of waiting for physical and psychological readiness.

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  Discuss development of fears, such as darkness or loud noises, and
of habits, such as security blanket or thumb sucking; stress
normalcy of these transient behaviors.

 Prepare parents for signs of regression in time of stress.

 Assess child's ability to separate easily from parents for brief

periods under familiar circumstances.

 Allow parents to express their feelings of weariness, frustration,

and exasperation; be aware that it is often difficult to love toddlers
at times when they are not asleep!

24 to 36 Months Old

 Discuss importance of imitation and need to include child in

activities.

 Discuss approaches toward toilet training, particularly realistic

expectations and attitude toward accidents.

 Stress uniqueness of toddlers' thought processes, especially through

their use of language, poor understanding of time, causal
relationships in terms of proximity of events, and inability to see
events from another's perspective.

 Nutrition: Toddlers usually require three meals and two snacks per
day. The ritualism of this age also dictates certain principles in
feeding practices. Toddlers like to have the same dish, cup, or
spoon every time they eat. They may reject a favorite food simply
because it is served in a different dish. If one food touches another,
they often refuse to eat it. it is best to use plastic dishes and cups
for both economic and safety reasons.

- Toddler needs 1300 calories/day.

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 - Diets high in sugar should be avoided.

- Adequate calcium and phosphorus intake is important for bone

mineralization.

89
Growth and development of
preschool child

Assist.Prof. Eman Hassan

91
Growth and development of Preschool (3 to 6 years)
- Physical growth
Weight
- The preschooler gains approximately 1.8 kg/year, 3year = 14kg
Height
Child doubles birth length by 4-5 years of age.
Formula to calculate weight and height are the same as toddlers
- Physiological growth
Vital signs
1. Pulse: 80-120 beat / min (average 100 beat / min).
2. Respiration: 20-30 cycle/ minutes.
3. Blood pressure: 100/67 + 24/25.
Motor Development:
At 3 Years
Gross motor
Rides a tricycle.
Fine motor
Copies a circle and imitates a cross and vertical and horizontal lines.
At 4 Years
Gross motor
- Hops, jumps, and skips on one foot.
- Rides a tricycle or bicycle with training wheels.
Fine motor
- Copies a square and traces a cross.
- Draws recognizable familiar objects or human figures.
At 5 Years
Gross motor
- Skips, using alternate feet.
- Jumps rope.
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Fine motor
Draws a stick figure with several body parts, including facial features
Cognitive Development:
The preschool up to 4 years of age is in the pre-conceptual phase. He
begins to be able to give reasons for his belief and actions, but not true
cause-effect
Language Development:
3years:
- Vocabulary of 800- 1000 words.
- Uses 4 words sentences.
- Ask why.
4years:
- Vocabulary of 1500 words.
- Uses 3 to 7 words sentences.
- Uses ―I‖ in his speech
5years:
- Vocabulary of 2100 words.
- Asks for the meaning of words.
Emotional Development:
Fears the dark
Tends to be impatient and selfish
Expresses aggression through physical and verbal behaviors.
Shows signs of jealousy of siblings.
Social Development:
The preschooler is in the stage where he develops a sense of initiative
versus guilt,
The child wants to learn what to do for himself, learn about the world
and other people.

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 Development a sense of guilt occurs when the child feels that his or her
imagination and activities are unacceptable
He is active imagination, creative and energetic.
Egocentric
Less dependent on parents
May have dreams & night-mares
Needs of Preschool child:
1- Security and independence
- The child feels love and security when he has two parents. He needs
their love and understanding.
2- Guidance
- The parents besides showing love for him must teach and guide him
toward maturity by suggestions not commands helpful the child in
forming good relation with other people.
3- Sex information
- Sex education during pre-school years is important.
- The child learns that he or she is a boy or a girl.
- Parents should answer the child directly and honestly.
4- Learning language
- The pre-school child learns to communicate his feeling and ideas.
- This is a period of rapid vocabulary growth.
- He also learns by imitating adult and other children.
5- Religious education
- Religious can be understood taught that ―God‖ loves him.
Problems of Preschool child:
- Thumb-Suckling:
- Encopresis
- Selfishness

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- Masturbation
- Enuresis
- Bad language
- Hurting Others
- Destructiveness
Care of Preschool child:
1- Physical Care
- Pre-School child is gaining competency in self -care. Feeling of security
in his home environment will help him to become independent in self-
care.
- He needs help in his bath.
- He learns to feed himself, to dress and undress, to wash his face and
hands, to brush his teeth and to toilet himself.
2- Sleep patterns
- The average pre-school sleeps 11 to 13 hours per day.
- The sleep of the 3-years old is frequently disturbed at night.
- Sleep problems are common and include, nightmares, night terrors.
- Most pre-school needs an afternoon nap until age 5 years.
- Bedtime rituals persist.
3- Safety measures
- Since pre-school children have more freedom, playing outdoors alone
and frequently away from the safe environment, more accident are likely
to occur.
4- Health supervision
- Regular visits for physician are important at intervals usually every six
months or yearly.
- The physician or nurse give complete examination as visual and
auditory perception for the child should be records the growth, give

94
advises about nutrition and any problems which occur in the management
of the child.
5- Nutrition
- The pre-school child is less interested in eating than he was during
infancy because he interested in exploring his environment.

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 Nursery School
Objectives:

By the end of this unit, the student will be able to:

 Define the meaning of nursery school

 Identify the objectives of nursery school experience for the nurses

and children

 List reasons for sending the child to nursery school

 Identify methods of preparing the child for nursery school

 Mention the factors affecting the child's learning experiences in

the nursery school

Definition:

Nursery school is a place where young children learn and share

experience with teachers and other children. Children from 3 -5 years are
accepted in nursery school.

Objectives of nursery school experience for nurses: -

1- Gain knowledge and understanding of normal growth and

development of the preschool age child (3-5 or 6 years) i.e. to
know what to expect of a child at this age.

2- To develop skills in anticipating the needs of the preschool, age

children and how these needs are met in the nursery school
through different activities and play materials.

3- Help the students to recognize and accept individual difference in

children with whom she work's

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4-To help nurses recognize the influence of the family and its cultural
pattern on the behavior of the child.

Objectives of nursery school experience for children: -

l- Promoters growth and development and improve the general

health of the child.

2- Increases the child's independence, self confidence and feeling

of securing.

3- Increases the ability to handle emotional constrictively.

4- It broadens his intellectual horizons.

5- prepare children for entering school

6- Enable child to cope with the outside world.

7- Education of religion and moral

Qualifications:

 The criteria for selection of the nursery school include the

qualification of the proportion of teacher to the child, physical set
up, the teacher, health policies and the educational methods.

Reasons for sending child to nursery school:

1-When the mother must work outside the home to help support the
family.

2- When the child needs socializing- experience of contact with

other children under the direction of well qualified people.

3-When the child needs educational experience to supplement what

receives at home, which is given also through interacting with

97
 other children form different socioeconomic and cultural
background.

Activities (curriculum experiences in the nursery school): -

 Play

 Play which is the heart of the nursery school curriculum, is

considered also the child's life. The child learns through play, by
imitating others and repetition.
 It enhances the physical and cognitive development by providing
opportunities for coordination of fine and gross motor
development.
 It nurtures the social development by providing situations where
the child can imitate and practice adult rule.
 Play also helps the children in discovering their world and satisfies
their curiosity.
 Music

 It should part of every curriculum.

 Each nursery should contain a piano or any musical instrument.
 Rhythm and tone in music are found to be similar to that of
mother's singing to her child which is very important for the child
in this age.
 Music helps children to learn to appreciate music and to develop a
sense of rhythm.
 It helps to taste music and enable them to be talented.
 Art

 Art materials should always be available for use. It helps in

expression of feeling and develop personality, and creativity
through finger paints, crayons, clay.
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 Literatures

 Experience with books as a part of the daily program provide the

children the learning experiences as it increases their vocabulary
and their intellectual ability as well as story telling,

 Reading groups should be small in number. Read slowly so that

the children will able to understand it.

 Books should be attractive and of interest to the children. A variety

of book should always be available.

 Books should contain interesting stories that should be short,

written in simple language, well illustrated in colors and at the
level of the child.

Preparing, the child for nursery school:

1 - Preparation starts with the mother's confidence in the school she

selects.

2- Take the child to the building when the school is not in session
to be familiar with the physical surroundings before the child is
left with strange adults and children.

3- child could bring a toy or game or something else from the home
to make concrete the continuing of school life with that at
home.

4- Assure him that mother will return

5- Mother stays with child on the first day and continues to come
until he feels secure without her.

99
Factors affecting the child's learning experiences:

1-factors related to the nursery school and teacher.

A- The number of children in a group: The number of children

should not be large usually less than 20 children in a group.

b- the teacher- student ratio: These will be at least one teacher to

every 8 to 10 children.

c-The length of the school day.

d)The physical set up: A well-planned building should be

promoted by such things as low shelves, low toilets, wash
basins; small chairs and tables sound proofing reduce noise
without the need of restricting children's activities

2-factors related to the child.

a- The previous experience in being in group of children

b-The type of home that child come from and environment.

C-The child's age, if a child is younger and smaller than others in a

group, he will often have difficulty in making social adjustment.

d- Children make rapid change in social adjustment in a very short

time if placed improper environment and under proper guidance.

111
Growth and development of School Age Children

Prepared by

Dr. safaa ramadan

111
 Growth and development of School Age Children

Objective:

At the end of this lecture the students will be able to:-

 Identify the school age period.

 Describe growth and development milestones of a school
age child (6-12 years).
 Summarize needs and problems of school age children

Introduction:

The child entering new phase of life at 6-7 years. It creates new
and more complex behavior pattern. Beside that their privacy makes them
to take physical care of himself. During the school age the growth is slow
until puberty the child is characterized by slow in growth of height but
gain in weight. In this stage boys are differ in growth in height and
weight than girls boys are taller and heavier than girls.

School age: That the period from 6 to12 year. It is characterized by

eruption of permeated teeth and finished by beginning the puberty.

Physical growth

The growth is gradual until puberty .

Weight:
School-age child gains about 3.8 kg/year.
 Formula is(age in years ×7) –5
2

Weight at 6 years → 20kgm.

weight at 12 years → 40kgm(double weight at 6 years).

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 Height :

The average gain in height 6cm/ year

 Formula is the same as toddlers and preschoolers .

at 6 years → 117cm.

at 12 years → 150cm(3 times birth length).

Dentition:Permanent teeth erupt during school-age period, starting from

6 years

Head circumferences
At 6 years ……………………………….. 51cm
At 12 years ……………………………… 53cm
Chest circumference (CC) is more than head circumference (HC)
Mid arm circumference at 12 years it is 17 to 18 cm.
Physiological growth

Vital signs :

Temperature: 37o C
Pulse: 95 beats /min

Respiration:19-21 c/min

Blood pressure: 100/60 mmHg.

GIT system: maturation in GIT & the child able to digest any food.
Genitourinary system: is maturity in kidneys are better to concentrate
urine.
Circulator system: soft heart sound
Neurological system: improved in memory & ability to
conceptualization & full voluntary control of fine motors function.

113
Skeletal and muscular development: Muscles ach are more complain at
this age so good posture should be encourage and good standing
position.
Endocrine systemis matured expect reproductive function
The immunological system: that function is to eliminate the foreign to
the body so the lymphoid tissue is matured.
The sense organ: the smell and taste, the child can differ between objects
at this stage.
Motor Development :

At 6 – 8 years

 Ride a bicycle .
 Runs, jumps, climbs, and hope .
 Can brush and comb hair .

At8- 10 years

 Beings to participate in organized sports .

 Use both hands independently .
 Prints fluently .
 Increased smoothness and speed in fine motor control .

At 10- 12 years

 Enjoy all physical activities .

 Motor coordination continues to improve
 Psychosexual development according to "Freud":he termed this
stage "latency period" in which the school child turns his
attentionand focus from sexuality to tasks of socialization and
development ofself-esteem.

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Cognitive Development:

 At 7-11 years, the child able to function on a higher level in his

mental ability, give similarities and differences between two things
from memoryand able to understand past, present, and future.
 Greater ability to concentrate and participate in self-initiating quiet
activities that challengecognitive skills, such as reading, playing
computer and board games .
 According to "Piaget" the child is in the stage of "concrete
operation"

Language Development:

- Sentence structure and use of grammar continue to improve.

- Talk in full sentence.

- Speech proceeds from egocentric to social .

Emotional Development:

o Fears injury to body and fear of dark .

o Jealous of siblings (especially 6–8 years old child).
o Curious about everything .
o Has short bursts of anger by age of 10 years but able to control
anger by 12 years .

Social Development:

o Continues to be egocentric .
o The child develops sense of Industry
o Failure to develop a sense of industry result in inferiority (feelings
of inadequacy) andchild become more isolated.

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  Psychosocial development according to "Erikson":Erikson termed
the psychosocial crisis faced by child aged from 6 to 12 years
"industry versus inferiority".

Needs of school age children:

 Sleep and rest.

 Bathing
 Nutrition
 Exercise and activity
 Dental health
 Education:

a- Sex education. b- Religious education .

School age problems :

a) School phobia: All organic cause must be ruled out before school
phobia. The most commoncomplaints are abdominal pain,
headache, vomiting, and regression .
b) Learning difficulties:The learning difficulties are represented in
variety of specific learningdisabilities in children. The difficulties
are in reading, writing, and understanding.
c) Behavioral problems:Children sometimes employ aggressive,
negative or disobedient behavior in an attempt to feelimportant and
control others. The forms of aggression are :

a- Lying b- Stealing c- Cheating

*Health education:Encourage the rewarding system for desired

behavior rather than punishing the undesired behavior .

d) Nutritional problems:

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 A. Overfeeding (obesity) B. Underfeeding

* Informing parents about qualities of foods rather than quantities .

e) Communicable diseases:

E.g.:Diphtheria, Typhoid fever, Hepatitis A virus .

*The nurse should assess the immunization status of school age and
review the times when boosterdoses are needed .

f) Allergy:
o Bronchial asthma, sinusitis, urticaria.
o Streptococcus & staphylococcus infection
- Streptococcus infectionas tonsillitis, rheumatic fever
- Staphylococcus infection as nephritis
g) Dental problems:
o Good oral hygiene habits and brushing should be done after meals .
o Referral to dentist every period for dental check-up.
h) Skeletal problems:
- Bone fracture
- Scoliosis
i) Accidents:
- Motor car accident
- Drowning
- Electric shock
* Instruct parent about first aids & methods of prevention these
accidents.

Red flags in school age child development:

 School failure.
 Lack of friends.
 Social isolation.
 Aggressive behavior:fights, fire setting, animal abuse.

117
 Adolescence
(Age 12 to 18 Years)

Prepared by

Dr. AsmaaAwad

118
 NORMAL GROWTH AND DEVELOPMENT OF
ADOLESCENCE
(Age 12 to 18 Years)
Objectives:
At the end of this lecture the student should be able to:
Explain changes that take place in the body.
Describe physical, mental and psychosocial development of
adolescents.
Advise parents on how to deal with children in this stage.
Discuss problems related to this stage.
Introduction

One of the most rewarding experiences of parenthood is the realization

that your child is suddenly a lovely and responsible adult. Adolescents
grow and develop in more ways and more quickly than children are at
any other stage. They change in three ways:

Physically.
Cognitively.
Psychosocially
The age of adolescence is generally regarded as 11-19 years. It is the time
for:

Transition from childhood to adulthood.

Formulating a sense of personal identity.
Gaining freedom from the family unit.
Sometimes driving parents out of their minds.
According to recent research, the brain is not completely
developed until late adolescence.

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 Changing hormonal levels activate development of secondary
sex characteristics:
Growth of pubic hair.
Menarche.
Growth Spurt:

Physiologically, developmental age is calculated by skeletal age.

Although trunk growth accounts for the greatest increase in adolescent’s
height, the sequence of growth begins in the extremities. During this
sequence both sexes may worry about sex-inappropriate changes.

Sex hormones

They influence epiphysis (growth plate) closure in the long bones

of the extremities, causing a close relation between the pace of
maturation and eventual height.
The predominant female sex hormone, estrogen, stimulates the
accumulation of more subcutaneous fat in girls creating a softer
curved appearance.
Testosterone, the important male sex hormone, stimulates greater
growth in denser bone and muscle tissue and therefore causes a
greater weight gain in males.
Skin Characteristics:

The increased activity of the sebaceous glands contributes to acne.

These glands produce sebum, a mixture of fatty acids, lipids, and
sterols, which helps to keep the skin moist by inhibiting the
evaporation of water.
The environment influences the amount of secretion; more sebum
is produced in hot, humid climate.

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 Increased sweat gland activity requires careful cleaning of the body
and airing and cleaning of clothes.
Body Proportion Changes:

Sex differences are apparent in body proportions as well as in height and

weight gains.

The straightening of the facial profile, with greater projection of the nose
and prominence of the jaw, is more marked in males; male growth also
results in broader shoulders, with relatively narrower hips and larger legs
in proportion to trunk length. The shoulders of females are narrower, the
hips are wider, and the legs are shorter in relation to trunk length.

Menstrual Cycle:

Menstrual hygiene requires special attention because the irregularity

of girls’ early menstrual cycle often leads to embarrassment caused by
soiled clothes, hygienic care. Frequent bathing and changing pads are
important points to be taught.

Nutritional Needs:

 Adolescence is a nutritionally vulnerable time because of the increase

in physical growth and the accompanying changes in life style and
food habits.
Adolescents show a markedly increased need for calories especially
during the growth spurt. The observation that teens, especially males,
seem to be hungry and eating all the time may
 relate to an imbalance between the size of the stomach and the amount
of calories needed.
The average caloric needs are as following:

Females: 11-14 years 2200 calories.

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 15-18 years 2100 calories.

Male: 11-14 years 2700 calories.

15-18 years 2800 calories.

Physical Health.

 Puberty marks the beginning of accelerated physical growth which

may double nutritional requirements for:
 Iron.
 Calcium.
 Zinc.
 Protein.
 Growing independence, the need for peer acceptance, concern with
physical appearance as well as active lifestyle may affect:
 Eating habits.
 Food choices.
 Nutrient intake.
 Nutritional status.
Cognitive Development.

Their thinking:

 Applies to possibilities as well as the realistic.

 Relates to the future as well as the present.
 Is evident in hypothetical-deductive statements.
 Demonstrates logical reasoning.
 Advances in thinking can be divided into several areas:
 It includes a more logical thought process and the ability to think
about things hypothetically (suppositional, conditional).
 It involves asking and answering questions.

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  Developing abstract thinking skills means thinking about things
that cannot be seen, heard or touched (faith, trust, beliefs,
spirituality).
Physical Development

Voice changes.
Growth of underarm hair.
Facial hair growth.
Increased activity of sweat glands.
Increased production of oil and acne.
Body parts do not grow all at the same rate.
This can lead to clumsiness as they try to cope with limbs that
seem to have grown overnight.
They frequently sleep longer. They need more sleep to allow their
bodies to conduct the internal work required for such rapid growth.
Others may be concerned because their physical development is
not at the same rate as their peers.
They may feel shame about demonstrating affection to the opposite
sex parent.
An adolescent girl who used to hug and kiss her dad when he
returned home from work may now shy away.
A boy who used to kiss his mom good night may now just wave to
her.
Characteristics of Adolescent Thoughts‖Cognitive Development‖.

 Egocentric thinking:
Thinking more about themselves than about others.

 Imaginary audience:

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 Thinking everyone is looking at them. They are painfully self
conscious.

 Personal fable: Seeing themselves as unique and powerful.

 Their beliefs in their abilities is inflated.
Psycho-social Development.

There are 5 recognized psychosocial issues that teens deal with:

 Establishing an identity:
 The question of ―who am I?‖ is not one that teens think about at a
conscious level.
 Establishing autonomy:
 They live by their own set of principles of right and wrong.
 They have become less emotionally dependent on parents.
 Autonomy is a necessary achievement for them to become self-
sufficient in society.
 Establishing intimacy:
 Intimacy refers to honest, caring and trusting relationships. It is
not the same as sex.
 Practice social skills and become intimate.
 Becoming comfortable with one’s sexuality:
 Achievement:
 Because of cognitive advancement they are able to see the
relationship between their current abilities and their future.
 They need to figure out what their achievements are.
 Preferences are what they are currently good at and areas in
which they are willing to strive for success.
Psychosocial Adjustment.

Adolescents experience many emotional events, such as:

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  Dealing with their changing bodies.
 Changing expectations from others.
 Involvement with opposite or same-sex partners in intimate
relationships.
Developmental Theorists

Erikson Freud Piaget

Identity V. Identity Genital stage Formal operational

Confusion (11 years and up)

Conclusion:

 Growth and development during adolescence is a multi-faceted

process involving every aspect of young persons.
 It is rapid and can be confusing and distressing.
Adolescents can make it through this turbulent time with minimal
damage and with a vision to a positive future as contributing adults if
they are given adequate:

 Support.
 Guidance.
 Firm limits.
 Unconditional love.

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Health Promotion of Children

Prepared by

Dr .safaa Ramadan

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 Health Promotion of Children

Objectives: -

 Define health promotion.

 Identify the goals of health promotion.

 Explain united nation declaration of child's right.

 List element of primary health care.

 Describe the components health promotion.

Introduction

Health promotion during childhood and adolescence is vitally

important because during these critical periods of the life span that the
learning of health-related behaviors, attitudes, values and perceptions
takes place.

Definition of Health Promotion

Health promotion comprises efforts to enhance positive health and

prevent ill, through the overlapping spheres of health education,
prevention and health protection.

Examples include providing information and resources in order to:

 Enhance nutrition at each developmental stage

 Integrate physical activity into the child’s daily events

 Provide adequate housing

 Promote oral health

 Foster positive personality development

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Goals of Health Promotion

The overall goal of health promotion is to promote health (physical,

mental and social) of children in different age groups.

Health
education

Health Diseases
protection
prevention

Three overlapping spheres of health promotion

A. Health education

Defined as any activity that promotes health related learning

B. Diseases Prevention

Level of Prevention: Prevention has three components, primary,

secondary and tertiary.

 Primary prevention: (health promotion and specific

protection) this involves activities that preventing the
occurrence of disease or injury through health teaching such
as giving immunization for prevention of illness or teaching
about car safety seats for prevention of injury

 Secondary prevention: (Early diagnosis and early treatment)

to lessen the disease severity. It aims to stop the development
of disease or handicapping conditions by early detection and
appropriate action e.g. through screening programs designed

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 to discover deafness in babies, hearing aids. Special teaching
and parental guidance, which lead to the best development of
speech and quality of life.

 Tertiary prevention (Rehabilitation): This involves

preventing deterioration, by appropriate treatment,
rehabilitation or palliative care. It involves providing support
both emotional and practical advising and information giving.

LEVEL OF PREVENTIVE HEALTH

Level Description Actions

Primary prevention Activities that decrease Giving immunizations

opportunity for illness or Teaching about car safety
injury seats
Secondary Early diagnosis and Developmental screening
prevention treatment of a condition to Vision and hearing screening
lessen its severity
Tertiary prevention Restoration to optimum Rehabilitation activities for
function child after a car crash

C- Health protection

 It is concerned with legal and fiscal measures, regulations

and policies and voluntary codes of practice.

 The aim of this sphere is to empower people to make

healthy choices.

 Protecting health by providing low cost housing to prevent

homeless children or unsatisfactory living conditions.

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United nations’ declaration of the child's rights
(20th November 1959)

All children need:

 To be free from discrimination.

 To be develop physically and mentally in freedom and dignity.

 To have a name and nationality.

 To have adequate nutrition, housing, recreation, and medical

services.

 To receive a special treatment if handicapped.

 To receive love, understanding, and material security.

 To receive an education and developed his or her abilities.

 To be protected from neglect, and abuse.

 To be brought up in a spirit of friendship among people.

Element of primary health care

 Education concerning prevailing health problems and methods of

preventing and controlling them.

 Promotion of food supply and proper nutrition.

 The provision of safe water and basic sanitation.

 Maternal and child health including family planning.

 Immunization against the major infection diseases.

 Prevention and control of locally endemic diseases.

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  Appropriate treatment of common diseases and injuries.

 Provision of essential drugs.

Setting for practicing health promotion

Homes, dispensaries, health centers, hospitals, school, factories,

health institutions and private health facilities. So, health
promotion can be provided to people where they live and work.

Components of Health Promotion

The component of health promotion includes:

1- Nutrition
2- Injury Prevention
3- Play
4- dental Care
5- Sleep
6- Immunization
7- Parental guidance

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Accident
prevention

Prepared by

Dr. Eman Hassan

122
 Accident prevention
Definition:
Accident is an unexpected event resulting in a recognizable injury.
Accident kills and cripples more children than any disease. If parents
understand their child's activities at certain ages, they can prevent many
serious injuries by taking necessary precautions. The toddler especially
vulnerable because he has a natural curiosity for investigating his
environment.
Common types of accidents among children
1- Automobile accident:-
Automobile accidents are the leading cause of death and crippling of
children.
Methods of prevention
1- Teach children to look both ways before crossing the street and the
meaning of traffic lights.
2- Hold the toddler's hand when crossing.
3- Use car seat for children or seat belts.
4- Don't allow children to ride in the bake of open trucks.
2- Burns
Children are fascinated by fire; they like to play with matches and
candles.
Methods of prevention
1- Teach the child's the meaning of hot.
2- Put matches and cigarettes out of reach and sight.
3- Turn handles of cooking utensils to the back of the stove.
4- Don't leave the bathroom when hot water is running or after the by
has filled.
5- Cover electric out lets.
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 6- Test heated foods before putting them in front of the child.
7- Keep a small fire extinguisher available.
8- Practice with the child what to do in case of fire at home.
3- Falls
Children experience a great number of falls in the process of growing
they need freedom to move, walk, run, climb, however, they most be kept
safe from situations that can result in sever bodily harm.
Methods of prevention
1- Teach children how to go up and come down safely and when they
are ready for this.
2- Mop spilled water from the floor immediately.
3- Place screen on all windows.
4- Suffocation and choking
The toddler loves to put objects into his mouth.
Methods of prevention
1- Remove small objects such as coins, buttons, and pins from the
children reach.
2- Don't allow children to play with deflated balloons as they can such
it into the trachea.
3- Don't feed pop corn, nuts, and small candies to small children.
4- Remove small bones from children and fish.
5- Keep plastic bags away from babies.
5- Poisoning
Poisoning is particular hazard for children between the ages of one and
four years. Children like to taste things especially if they are colorful.

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Methods of prevention
1- Store household detergents and other cleaning supplies out
of the child's.
2- Don't put chemicals into food or beverage containers.
3- Keep medicine in locked cabinet. Don't refer to pills as
candy. Flush old medicine down the toilet.
4- Wash fruits and vegetables before eating them.
5- Carry a first aid kit at home.
6- Avoid poisonous house plants.
Drowning
Children enjoy playing in the water which can be hazardous

Methods of prevention
1- Teach the child to swim when he is old enough.
2- Empty pools or bath tubs when the child has finished.
3- Stay with the child all the time when he is in the tub.
4- Remove basins of water from the child's reach.
5- Watch children constantly while at the beach or near pool

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Accident prevention in pediatric hospital
The nurse must follow and apply safety measures on the children's ward
the following is a list of measures that the pediatric nurse should follow:-
1- Keep crib sides up at all times when the patient is unattended in
bed.
2- Wash your hands before and after caring for each patient.
3- Check wheel chairs and stretchers before placing patients them.
4- Place fans out of reach of children.
5- Inspect toys for sharp edges.
6- Keep medications and solutions out of reach and sight of children.
7- Apply restraints correctly to prevent constriction of a part.
8- Identify the patient correctly before giving medications.
9- Prevent cross infection: Diaper care, toys and materials that belong
to one patient should not be used for another patient.
10- Locate fire extinguished in your unit.
11- Cap hot water bottle tightly.
12- Remain with the patient when taking temperature/
13- Handle infants and small children.
14- Don't force feeding to small children.
15- Don't leave medications at the bedside.
16- Don't give oily medications to a crying child because of the danger
of choking.
17- Don't allow ambulatory patients to use wheel chairs or stretchers
as a toy.
Parent need to be advised for how to prevent accidents for children
especially preschool children because child from 3-5 years usually
hurries up and down stairs and he plays hard with his toys.
1- Stair ways must be kept free.
2- Shoes should have rubber soles.
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 3- Toys should be sturdy and can take a heating.
4- Never ask he preschool child to do any thing that is dangerous like
carrying a glass container or knife to the kitchen sink.
5- Child should be taught where he can safety ride his tricycle and
where he can play ball , he must not play in or around the car.
6- Keep matches cigarette lighters and coffee or tea pots out of child
reach.
7- Keep medications out of the children reach because at this age
they like to imitate adults and having their pills especially if they smell
good.

127
Play

Prepared by

Dr. Eman Hassan

128
 Play
Introduction

Play is children's work. Children work hard at their play because they can
make it up themselves. The best part about children's play is that they
learn a great deal while having fun. Through play a child grows, Learns,
develops and matures.

Definition of Play

Play is the work of children. It consists of those activities performed for

self-amusement that have behavioral, social, and psychomotor rewards. it
is enjoyable and spontaneous.

Functions of play

1. Physical development

- Play aids in developing both fine and gross motor skills.

- Encourages exploration of the physical nature of the world
- Enhances development of all senses

Children repeat certain body movements purely for pleasure, and these
movements develop body control.

2. Emotional development

- Children who are anxious may be helped by role playing. Role

playing is a way of coping with emotional conflict.

- Children may escape through play into a fantasy world in order to

make sense out of the real one.

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 - A child's self-awareness deepens as he explores an event through
role-playing or symbolic play.

- The child's self-esteem gets a boost.

3. Cognitive development

- Children gain knowledge, abilities to think, remember, and solve

problems through their play.

- They develop cognitively as they have a chance to test their

beliefs about the world.

- Children also increase their understanding of size, shape, and

texture through play.

- Language is strengthened as the children model others and

organize their thoughts to communicate.

- Children increase their problem-solving abilities through games

and puzzles.

4. Social and moral development

- Play encourages interaction and development of positive attitudes

toward others.
- Reinforces moral standards
- As children grow, they enjoy playful interaction with other
children.
- Children learn about boundaries, teamwork, and competition.
- Children also learn to negotiate with different personalities and
the feelings associated with winning and losing.
- They learn to share, wait, and be patient.
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 - The child learns how to be kind and charitable to others.
- When children engage in play with their peers and families, they
begin to learn some behaviors are acceptable while others are
unacceptable

5. Creativity value

- Provide opportunity for creative ideas and interests

- Allow for fantasy and imagination

6. Self awareness value

- Facilitates the development of self identity

- Provides for comparison of own behavior affects others

7. Therapeutic value

- Provides for release from tension and stress

- Facilitates nonverbal and indirect verbal communication of needs,
fear, and desires

Types of play

1. Solitary

During infancy period, each infant likes to play with himself and his
body. The main purpose of play during infancy period is to gain
pleasure and to satisfy sensor-motor needs.

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2. Parallel

During the toddler years, the toddlers children play beside each other
and each child is concerned with his toy until he loses interests and
then look for something else.

3. Dramatic

Is common during the preschoolyears. Girls usually imitate their

mothers and boys imitate their fathers. They imitate social life
and learn social role.

4. Cooperative

Is common during the schoolyears. Childrenusually during this

age like to play in groups and like to share their games with
each other.

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 5. Day dreaming

Is common during the adolescence years. Children like to play

competitive games as well as abstract problem solving kind
of games.

What makes good play things?

 Simplicity of design
 Involve child in play
 Easy in use
 Easily comprehended & manipulated
 Encourage cooperative play
 Material that is warm and pleasant to touch
 Durable
 Work as intended
 Safe
 Generous in proportion and quantity
 Price based on durability, suitable and design

Importance of play during hospitalization

Play is very important for well and sick children, children during
hospitalization usually have unpleasant experience and they need
something to make them feel better and happy.

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Playing in the hospital will help the children to :-

o Express this feeling and tension

o Understand hospital procedures
o Accept treatment and be cooperative
o Be sociable and have friends from other units in the
hospital.

134
Infant Feeding and Weaning

Prepared by

Dr. AsmaaAwad

135
Types of infant feeding
-Natural feeding:-
-Brest feeding
Weaning

Definition

Techniques of weaning
Aim of weaning

Best time for weaning

Principles of weaning

Effect of premature weaning

136
Infants Feeding
Types of infant feeding
1- Natural feeding:-
- Breast feeding.
2- Artificial feeding:-
A. Enternal
Oral: - 1- Bottle feeding.
Gastric: - i.e., give milk directly in the stomach through
1- Nasogastric feeding (Gavage feeding). 2- Gastrostomy
feeding.

B. Parenteral
1- I.V fluids. 2- Total parental
nutrition (TPN).

1- Natural feeding:-
Breast-feeding:

The breast-feeding is the best method for newborn and preterm babies
and very important to maternal and newborn baby’s health. The exclusive
breast-feeding should be from birth up to 6 monthsof infant's age.

Benefits of breast-feeding to mother

 The infant's sucking promotes involution of the uterus after
parturition.
 Breast-feeding saves time, effort and is less of strain on family
budget.
 It lowers the incidence of cancer breast.
 It fulfills the feminine role and motherly attitudes.
 Breast-feeding use up the fat the mother stored up in pregnancy.

137
 Breast-feeding helps the mother to relax and feel calm. Once the
milk starts to flow, the hormones help mother to feel relax and
enjoy it.
 Exclusive breast-feeding can also help provide a healthy space
between children. But, breast-feeding does not provide complete
contraception.
 Breast-feed mothers are less liable to develop osteoporosis.
 Breast-feeding protects the mother from hip fractures. The longer
the breast-feeding, the greater the protection.

Benefits of breast-feeding to infants

 Breast milk is warm, ready, and sterile.
 Perfectly balanced in protein, carbohydrates, fat and
vitamins and does not cost anything.
 It is more easily digested than cow’s milk.
 Breast-fed infants have greater immunity to certain
childhood diseases, such as, chest infection, ear infection, as
it provides immunological factors to certain diseases.
 Infants are less likely to have gastro-intestinal disorders,
anemia and vitamin deficiency.
 Breast-milk is important for the brain and central nervous
system as well as the correct development.
 Infants who are not take exclusively breast-fed for at least
two months they have double risk of getting insulin-
dependent diabetes.
 Breast-feeding can protect the infant from allergies, such as,
enzyme and asthma. It is also recommended that infant from
families with allergies be exclusively breast-fed for at least
six months.

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  Breast milk is available all time.
 Infant is secure through constant with his mother and this
has an effect on the child’s psychological development.
Breast feeding reflexes
1. Maternal reflex
A) Nipple erection reflex.
B) Prolactine reflex from hypothalamus.
C) Oxytocin reflex from posterior pituitary gland.
2. Neonatal feeding reflex
A) Rooting reflex. B) Sucking reflex.
C) Swallowing reflex. D) Gavage reflex.

Criteria of Breast Feeding

1. Adequacy of breast feeding
 Infant calm, satisfied after feed.
 Normal motion (stool).
 Normal weight gain.
2. Underfeeding
 Infant always crying, failure to gain weight.
 Dehydration, constipation, sleeplessness, colic.
3. Overfeeding
 Regurgitation, vomiting, colic.
 Large Bulky stool, abdominal distension, excessive
sweating.

Contraindication of breast feeding

1. Related to mother
- Infectious disease of the mother like (active T.B).
- Mental disease (epilepsy, hysteria, toxic drugs).
- Lung disease, cancer. - Pregnancy.

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2. Related to infant

- Inborn error in Metabolism.

- Allergy to Breast milk.
- Severe congenital anomaly (cleft lip/palate).

Difficulties in feeding
1. Defect in infant
A) Nasal catarrhal, stomatitis, soreness of mouth.
B) Congenital anomalies, premature, facial palsy.
2. Defect in mother
A) Twins pregnancy.
B) Poor development of breast, sore nipple, engorgement of breast,
mastitis, breast abscess
Feeding position:

A. Foot-ball hold. B. Side lying position

C. Cradle position. D. Cross cradle position.
E. Horizontal position

A) Foot-ball holds
B) Lying down

C) Cradling D) Across the lap

Horizontal

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Role of the nurses in breast feeding
1. The nurse must help mothers to initiate breast-feeding an hour
after birth.
2. The nurse should demonstrate to mother how to practice breast-
feeding successfully, i.e., the technique of feeding, which
includes correct positioning and attachment.
4.The nurse must explain to mothers that when the infant appears
to have a weak or ineffective sucking or when mother is not
available to feed her infant such as working mothers, milk
expression is necessary. Milk expression helps to initiate the
letdown reflex and stimulate the infant to breast-feed. The nurse
must consider the alternative methods of feeding such as spoon,
cup or tube feedings of expressed milk.
5.The nurse should explain techniques for milk expression and
storage of breast milk.

141
 Weaning
Definition
Weaning is the process of giving up one method of feeding for
another, usually refers togiving up of the breast or bottle feeding to a
mixed diet. It is the period of transition during which child whose main
food was milk changes to be adult food.
Aim of weaning
1- The child cannot tolerate more than one liter of fluid per day so,
with his increasing needs for energy more solid foods should be
added.
2- With growth, the baby requires more food item, minerals and
vitamins, which cannot be all supplied by milk alone.
3- To train the GIT to digest starch and other solid foods.
4- To educate the child independence by using spoon and cup.

Best time for weaning

Weaning should be delayed for 6 months of infant's life. Because
Breast milk contains high level of immunoglobulins antibodies (IGA),
which protect the immature gut wall till this time.

Principles of weaning
1- Weaning should be gradual to prevent GIT disturbance.
2- Weaning should be not start in summer because of the high
susceptibility to gastroenteritis.
3- Weaning should be not start during convalescence from any
disease.
4- Weaning should not start if the infant is underweight to avoid
gastrointestinal disturbance.

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Effect of premature weaning
1- Early weaning has been implicated as cause food allergy,
indigestion, constipation or diarrhea.
2- Weaning too early is not tolerated due to immaturity of
gastrointestinal tract, liver, and kidney.
3- Excessively early weaning avoided because it may result in fat
baby or trigger allergies.
4- Early introduction of food and the early discontinuation of breast-
feeding are associated with increase risk of diarrhea also excessive
rate of morbidity from infectious disease.

Techniques of weaning
1- Weaning start at the age 6 months by replacing milk feed by semi-
solid food.
2- This should be continued gradually by replacing other milk feeds by
foreign food until all food is replaced at the age of 1-2 years.
3- The new food is given gradually and in small amount at first if
accepted by the baby the amount can be increased.
4- Never force the infant takes a new food.
5- The presentation of food is important so better use colorful attractive
spoon and plates to stimulate babies' interest and appetite.
6- New food item should be introducing one at a time usually intervals of
4-7 days to allow for identification of food allergies.
7- Introduce solids when infant is hungry.
8- As the amount of solid food increase, decrease the quantity of milk to
prevent overfeeding.
9- Do not introduce foods by mixing them with the formula in the bottle.

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Role of the nurse
1- The nurse must assist parents and start to teach them weaning
technique and its importance to their infant.
2- Factors to be considered as this process is discussed with the
parents include developmental readiness of the infant, the baby
sucking needs, parent believes and feelings, finance, and nutritional
requirements.

144
 Immunization

Prepared by

Dr.safaa Ramadan

145
 Immunizations

Out lines:

- Definition of immunity
- Definition of immunization
- Types of immunity
- Types of immunizations
- immunization schedule
- Contraindications and precautions
- Nursing responsibilities

Infection

Infection is the invasion and multiplication of micro-organisms in

the body. Infection can cause numerous illnesses during childhood, most
of which are common, but some of which are less common or even rare.
The severity of illness caused by infection can range from subclinical to
life-threatening. A thorough understanding of the etiology and symptoms
of infectious diseases as well as the appropriate diagnostic and
therapeutic interventions will help the nurse provide optimal care.

Chain of infection

Chain of infection is a term used to describe the circle of links needed

for the transmission of infectious diseases in humans. All links must be
present and in order for an infection to occur.

1) The chain begins with a pathogen that’s capable of producing

disease in humans, that is, bacteria, virus, fungi, or parasite.
2) The reservoir of an infectious agent. This is where the infectious
agent will grow. Humans are the most common reservoir. Other

146
 reservoirs include the environment, hospital settings, water supply,
and rodents or animals.
3) The third link in the chain is the portal of exit. The pathogen
leaves the reservoir via mucus, blood, or feces.
4) The mode of transmission. The two main ways that an infection
can be transmitted from its reservoir to a susceptible host are via
direct transmission or indirect transmission.
5) The fifth link in the chain is the portal of entry (the site where
disease transmission occurs), through which a pathogen can enter
the body by penetrating the skin or a mucous membrane barrier by
direct contact or ingestion.
6) The last link is the host; a susceptible host is necessary for an
infectious disease to be transmitted.

Immature immunity

Infants and children are susceptible to infectious diseases because their

immune systems are immature. As children mature and grow, their
147
exposure to infectious agents increases and they develop antibodies
naturally. Subsequent infections with the same pathogen may be less
severe or avoided completely

Stages of infection

Infections follow a predictable sequence of events during transmission

that results in five distinct stages of disease.

1. The incubation period is the phase during which the pathogenic

organism begins active reproduction in the host; the child has no
clinical symptoms but may be contagious to others during this
time.
2. The prodromal phase is the initial appearance of clinical symptoms
in the host; common symptoms include fever, malaise, headache,
sore throat, cough, and rhinitis.
3. During the acute stage, maximum symptoms are experienced by
the host; toxins deposited by the pathogenic organism can produce
tissue damage. (Inflammatory changes and tissue damage can also
occur as a result of the immune response of the host.)
4. The convalescent stage is characterized by progressive elimination
of the infection (or elimination of the pathogen), healing of
damaged tissue, and symptom resolution.
5. The resolution stage is the host’s recovery from the infection
without residual signs or symptoms of disease.

The period of communicability is the time when the infectious organism

may move from the infected host to another person. It varies with
different disease states but usually begins during the incubation phase.

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Immune protection

Children receive protection from infectious diseases naturally and

artificially.

Methods of obtaining immune protection (Types of immunity)

There are five different methods in which immune protection can be

obtained: natural immunity, naturally acquired active immunity, naturally
acquired passive immunity, artificially acquired active immunity, and
artificially acquired passive immunity.

I. Natural (innate) immunity

Innate immunity is a combination of natural and nonspecific immunity
that can protect the human body from pathogens and foreign agents. For
example, the phagocytic action of white blood cells (macrophages) may
be triggered by the body’s innate ability to recognize and distinguish
normal cells from foreign cells. The body’s ability to distinguish self
from non-self is natural, or innate, immunity.

II. Naturally acquired active immunity

Naturally acquired active immunity is obtained when the body’s immune
system responds to a specific pathogen. Antibodies and memory cells
prevent or reduce the severity of subsequent infection with that specific
pathogen. Naturally acquired active immunity persists for many years.

III. Naturally acquired passive immunity

Naturally acquired passive immunity involves mother-to-fetus
transmission of maternal antibodies.

The mother’s immunoglobulin G crosses the placenta and is transmitted

to the fetus. After birth, the infant can receive passive immunity through
maternal antibodies in breast milk.

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for up to 2 months Naturally acquired passive immunity differs from
active immunity. Although active immunity lasts many years, or even a
lifetime, passive immunity lasts only as long as the anti-bodies remain in
the blood of the fetus or infant (usually from a few weeks to about 2
months). Even so, some antibodies transferred across the placenta have
been isolated up to age 1 year, which is why measles immunization must
be delayed until age 15 months.

IV. Artificially acquired active immunity

Artificially acquired active immunity is achieved by deliberate
administration of a vaccine or toxoid. The vaccine or toxoid stimulates
the immune system’s production of antibodies against a specific antigen,
but symptoms of the disease aren’t produced in the person receiving the
vaccine.

V. Artificially acquired passive immunity

Artificially acquired passive immunity is conferred when antibodies
developed in another person or animal donor are injected into an
individual. In pediatric patients, this transfer usually involves intravenous
(I.V.) administration of a specific immunoglobulin, or antisera. Examples
include:

• gamma globulin (a mixture of antibodies against prevalent community

diseases, pooled from 1,000 human plasma donors)

• hyperimmune or convalescent serum globulin (such as tetanus antitoxin,

hepatitis B immune globulin, and varicella-zoster immune globulin).

Definition of immunization

the process of inducing or providing active or passive immunity

artificially by administrating an immunobiologic.

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Types of immunizations

Various immunizations are given at specific times to protect pediatric

patients from certain diseases. These vaccines fall into following
categories:

• live, attenuated vaccines

• inactivated vaccines.

 Toxoids

Live, attenuated

Live, attenuated vaccines are created from a live organism that’s grown
under suboptimal conditions to produce a live vaccine with reduced
virulence.

Thus, an attenuated immunization contains weakened microorganisms

and stimulates immune response and production of antibodies in the host.
The vaccine confers 90% to 95% protection for more than 20 years with a
single dose. Examples of live, attenuated vaccines include the measles,
mumps, and rubella (MMR) vaccine; the rotavirus vaccine; and the
varicella vaccine

Inactivated

• An inactivated, or killed, vaccine confers a weaker response than a

live vaccine, necessitating frequent boosters.

• An inactivated vaccine doesn’t promote replication and provides 40%

to 70% protection.

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 Toxoids

Some bacteria, such as diphtheria, produce toxins, which cause disease.

The vaccine to prevent a disease caused by a toxin is called a toxoid.
A toxoid:

• is another form of an inactivated vaccine

• is a toxin that has been specially treated with formalin or heat to

weaken its toxic effect but retain its antigenicity

• provides 90% to 100% protection by stimulating the production of

antibodies.

Examples of inactivated vaccines include:

• diphtheria and tetanus toxoids

• inactivated poliovirus vaccine (IPV)
• pertussis vaccine
• hepatitis B vaccine.

Immunization schedule

Childhood immunizations include the hepatitis A and B vaccines,

diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine,
Hemophilus influenzae type B (Hib) vaccine, human papillomavirus
(HPV) vaccine, influenza vaccine, IPV vaccine, meningococcal vaccine,
MMR vaccine, rotavirus vaccine, varicella virus vaccine, and
pneumococcal 13-valent conjugate vaccine (PCV). These immunizations
are usually given according to a predetermined schedule.

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 Immunization schedule for children in Egypt

Contraindications to vaccine administration

Mild illnesses and low-grade fevers that are common in children aren’t
contraindications to vaccine administration. However, there are several
reasons to withhold or delay vaccine administration:

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• Vaccination is contraindicated in patients with moderate to severe
illness or a history of allergic response or anaphylaxis to the vaccine or
certain antibiotics.

• Vaccination with preparations containing live or attenuated viruses

shouldn’t be performed in patients who are pregnant, have an
immunodeficiency disease, or are receiving immune-suppressive
therapy.

• The DTaP vaccine shouldn’t be given to a child who has a progressive

and active central nervous system (CNS) problem. However, a child
with cerebral palsy can receive immunizations.

• The measles vaccine shouldn’t be given at the same time as a tuberculin

purified protein derivative test. The measles vaccine can make a person
who’s positive for tuberculosis (TB) appear to be TB negative.

Nursing responsibilities

Before immunization

• Obtain a history of allergic responses, especially life-threatening

anaphylactic reactions to antibiotics or past vaccinations (certain
vaccinations may be contraindicated in these children).

• Assess the child for moderate or severe illness. Vaccinations may be

delayed in these children until they recover. However, a child with a
minor illness, such as a cold, may receive immunizations.

• Keep in mind that children receiving corticosteroids for longer than 2

weeks, chemotherapy, or radiation therapy; those with human
immunodeficiency virus infection, acquired immunodeficiency
syndrome, or another disease that affects the immune system; and
those with cancer will need special consideration for vaccination.
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 (They may not be able to receive live virus vaccines, such as MMR,
rotavirus, or varicella vaccines.)

Tips for pediatric injections

• Give the child a simple, age-appropriate explanation for why the

injection is being given.

• Allow the child to give a ―shot‖ to a doll or stuffed animal; this gives
him a sense of control, lets him see that the injection has a beginning
and an end, and gives him a concrete understanding of what will
happen.

• Be honest; tell the child that it will hurt for a moment but that it will
be over quickly

Coping and comfort

• Give the child a coping strategy, such as squeezing his mother’s hand,
counting to five, singing a song, and looking away.

• Have a parent hold and comfort the child while the injection is being
given. A parent’s presence reassures the child that nothing truly bad
will happen. (The child may actually cry more when a parent is
present, but this is because he feels safe enough to do so.)

Praise and cover

• When the injection has been given, tell the child that ―the hurting part‖
is over, and praise him for what a good job he did (regardless of how
he reacted). Never tell a child to ―be brave,‖ to ―be a big boy,‖ or not
to cry, as these requests will set the child up for failure.

• Give the child a bandage. (A young child may not believe the ―hurting
part‖ is over until a bandage has been applied.)

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• Always give injections in a designated treatment area. Avoid
performing painful procedures in a playroom or, if possible, in the
child’s hospital room, because he needs to know there are places
where he can feel completely safe.

Giving the injection

• Apply firm pressure at the site for 10 to 15 seconds immediately

before giving the injection to decrease discomfort (a numbing patch
may be used).

• When two or more injections are needed, give them simultaneously in

different extremities; have two or more nurses to assist (and provide
manual restraint, if needed) during the procedures. (The child has only
one painful experience when multiple injections are given
simultaneously; this is believed to be less traumatic than receiving
painful injections one after the other.)

• Apply bandages to each site, and immediately comfort and console the
child following the injections.

• Always keep resuscitation equipment and epinephrine readily

available in case of an anaphylactic response to an immunization.

After immunization

• Tell the parents to watch for and report reactions other than local
swelling and pain and mild temperature elevation.

• Give parents the child’s immunization record.

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AIDS

Prepared by

Dr.Asmaa

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 Definition
Acquired immune deficiency syndrome (AIDS) is an infectious
disease caused by the human immunodeficiency virus (HIV). AIDS is the
advanced form of infection with the HIV virus, which may not cause
recognizable disease for a long period after the initial exposure. No
vaccine is currently available to prevent HIV infection.

 Causes or ways of transmission:-

1- Mother-to-child transmission.
Children infected with HIV were infected through their mother
either during pregnancy, labour and delivery or breastfeeding.In high-
income countries, preventive measures ensure that the transmission of
HIV from mother-to-child is relatively rare. This shows that with funding,
trained staff and resources, the infections and deaths of many children
could be avoided.
2- Exposure to contaminated blood or blood products.

HIV infection can occur in medical settings through needles that

have not been sterilized or through blood transfusions where infected
blood is used. The infections among children resulting from contaminated
injections and unscreened blood transfusion. This means that babies and
children were infected with HIV as a result of unsafe medical practices.
3- Sexual transmission.
Sexual transmission does not account for a high proportion of child
infections but in some countries children are sexually active at an early
age. This is potentially conducive to the sexual spread of HIV among
children.
Note:

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 HIV is not transmitted by handshakes, coughing or sneezing, or by
blood-sucking insects such as mosquitoes.

 Pathophysiology:-

HIV attacks the body through three disease processes:

immunodeficiency, autoimmunity, and nervous system dysfunction.

1- Immunodeficiency describes the condition in which the body's

immune response is damaged, weakened, or is not functioning properly.

2- Autoimmunity is a condition in which the body's immune system

produces antibodies that work against its own cells.

3- Nervous system dysfunction, since the virus can cause damage

without infecting nerve cells directly. Once infected with HIV, one type
of immune system cell, called a macrophage, begins to release a toxin
that harms the nervous system.

 Signs and symptoms:-

• Low-grade fevers.
• Chronic fatigue.
• General weakness.
• Food malabsorption.
• Loss of appetite.
• Suffer from a yeast infection in the mouth and other
gastrointestinal symptoms that cause malnutrition and weight loss.
• General loss of strength, loss of reflexes, and feelings of numbness
or burning sensations in the feet or lower legs.
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 Diagnostic studies:-
1- Physical examination for the signs and symptoms of AIDS.

2- Laboratory tests the polymerase chain reaction (PCR) test can be used
to detect the presence of viral nucleic acids in patient's blood.

* OTHER LABORATORY TESTS. In patients that have already been

diagnosed. These include CBC, viral load tests, p24 antigen assays, and
measurements of β2-microglobulin (β2M).

 Treatment

Treatment for AIDS covers four considerations:

1- Treatment of deferent infections and malignancies. Most AIDS

patients require complex long-term treatment with medications for
infectious diseases. This treatment is often complicated by the
development of resistance in the disease organisms.

2-Prophylactic treatment for opportunistic infections. Prophylactic

treatment is treatment that is given to prevent disease.

3- Anti-retroviral treatment. Researchers have developed drugs that

suppress HIV replication, as distinct from treating its effects on the body.

4- Stimulation of blood cell production. Because many patients with

AIDS suffer from abnormally low levels of both red and white blood
cells, they may be given medications to stimulate blood cell production

 Alternative treatment:-
Alternative treatments for AIDS can be grouped into two
categories:

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- Those intended to help the immune system and those aimed at pain
control. These like herbal medicine, special diets, massage, ect.

 Prognosis:-

Tell now, there is no cure from AIDS.

Prognosis after the latency period depends on the patient's specific

symptoms and the organ systems affected by the disease. Patients with
AIDS-related lymphomas of the central nervous system die within two to
three months of diagnosis; those with systemic lymphomas may survive
for eight to ten months.

 Prevention:-
- There is no vaccine effective against AIDS.

- Avoid needle sharing among intravenous drug users.

- Although blood and blood products are carefully monitored.

- Healthcare professionals must take all necessary precautions by wearing

gloves and masks when handling body fluids and preventing needle-stick
injuries.

 Complications:-

Abscess Encephalitis Meningitis

Nerve damage HIV encephalopathy

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 Hospitalization

- Definition:-

Hospitalization is admittance to the hospital as an inpatient.

- Purpose:-

Patients are admitted to the hospital for a variety of reasons,

including laboratory tests, surgery, emergency medical treatment,
administration of medication.

- Preparation:-

The child and his parents should take chance to be familiar with
this situation through

Parental Concerns or Fears:

Parents need to deal with their own fears about hospitalization.

The parents should learn all they can about their child's condition and
about the hospital, the child's health care team, and available services.

Learning about the hospital:

Many hospitals allow parents and children to tour the pediatric

facilities before the hospital stay. Children may be shown rooms similar
to that in which they will stay. The tour may include a visit to the unit's
playroom, a chance to meet the nursing staff, and to become familiar with
some of the hospital equipment.

Packing for the hospital stay:

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 The child should help the parent pack items for the hospital stay. It
is helpful to pack familiar pajamas, toys, games, and a special family
photo.

Selecting a family spokesperson:

The spokesperson helps maintain the patient's privacy and also

improves communication with the health care providers

- During Child's Hospitalization:-

The special support and involvement are very important to the

child’s sense of comfort and security during the hospital.

Establish good communication

Communication with the child’s health care providers can help the
child understand what is happening. Help in prepare your child for
procedures and tests. Start to till the child about symptoms, plan of care,
and give the child chance to give reaction.

Share with the child’s routine

With care providers, this will help to maintain the child’s daily
routine as much as possible.

Encourage the child to share some activity

Encourage the child to participate in activities and special

programs. It is easier for children to be in the hospital when they are
involved in interesting activities.

Stay in touch

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 There are some changes happen in the child’s personality or
behavior during hospitalization. Young children may become more
demanding. If the child recently has been toilet-trained or weaned from
the bottle, may temporarily regress. The Nursing staff can help the child
cope with these issues.

- Dealing with deferent children according age groups:-

Younger than 3

For a child less than 3 years of age, having close parental contact
during hospitalization is the best means of support. Young children
generally do not understand their illness or the hospital environment.
Help the parents to be with the child in the hospital this will help the
child to feel more secure.

Ages 3 to 6

This age group also wants to be near the family and often views a
hospital stay as punishment for something. Honest, simple, age-
appropriate conversations can help your child feel more secure.

Ages 7 to 12

Older children usually are worried about painful procedures and

changes to their body. Providing information is the key at this age. Don’t
mislead the child by saying something won’t hurt if it will. Instead, talk
with the child about how to cope with possible pain and confusion.

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Teenagers
Teens often are self-conscious and may have lots of questions
about specific procedures. Encourage the teen to talk to doctors and
nurses involved in the care and allow the teen to be part of decisions.
This will help the teen feel some degree of control.

- Risks of hospitalization:-

The risks of hospitalization are related to the type of treatment or

procedure the child will be having. The parents should discuss with the
child's doctor and health care team and understand the potential risks of
any procedure.

- Expected results:-

The health team should know how much fear of parents and child
about the end result after hospitalization and disease. Then the health
team should communicate properly and give them the real fact result but
it may be gradually.

- Discharge:-

Parental preparation for a child's discharge from the hospital is the

stage for successful care and recovery at home. It found that theParental
coping difficulty with post hospitalization health services. This is the
main role of the skilled nurse as a teacher in promoting positive outcomes
at discharge and beyond the hospitalization. This is through special
program of health education about child's needs and problems according
deferent age group

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 Nutritional
disorders(Malnutrition)

Prepared by

Dr. Azza Elewa

166
General objective
At the end of this module the student should be able to:
identify, assess, analyze and classify children with Malnutrition disorders.
Intended learning outcomes:
At the end of this module the student will be able to learn:-
Knowledge and understanding:
Identify the different types of malnutrition.
Discuss the meaning of malnutrition.
List clinical signs of the different types of malnutrition .
11-intellectual skills:
Analyze children at risk factors for malnutrition disorders.
Differentiate between kwashiorkor and marasmus.
Interpret the biochemical value of malnutrition
Explain the complication of nutritional disorders.
Apply the role of pediatric nurse in the management of malnutrition
diseases.
Plan nursing process for the child with malnutrition disease
Educate the mother of child with nutritional disorders.
111-professional and practical skills:
Assess the nutritional status of children with any type of malnutrition
disease
Carry out the prescribed medication and observe for the side effect of
medication.

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Out Lines
Introduction
Definitions
Prevalence of malnutrition
Etiology of malnutrition
Consequences of malnutrition
Definitions marasmus & KWO
Etiology of marasmus & KWO
Assessment of child and infant with marasmus& KWO
Complication of marasmus & KWO
Investigations for marasmus & KWO
Treatment & prevention of marasmus & KWO
Nursing management
Comparison between marasmus & KWO
Introduction
Malnutrition it is a condition that develops when the body does not get
the proper amount of protein, calories, vitamins and other nutrients it
needs to maintain healthy tissues and organ function .
It occurs in children who are either undernourished or over nourished.
Over nourished children may become over weight or obese and those
who are under nourished are more likely to have severe long term
consequences.
Definition
Is a term referring to poor or inadequate intake of one or more of the
essential nutrient. Malnutrition includes: under nutrition and over
nutrition.
-Under nutrition: is a consequence of consuming little energy and other
essential nutrients or using or excreting them more.

168
Malnutrition: is a term referring to poor or inadequate intake of one or
more of the essential nutrient
Causes of malnutrition
1-Dietetic errors: quantitatively or qualitatively
2-Poor food availability & preparation
3-Recurrent or chronic gastroenteritis.
4-Chronic infection by (T.B, otitis media)
5-Parasitic infestations: Ankylostoma, Ascaries, Giradia.
6-Malabosportion .
7-Lack of nutritional education
8-Lack of sanitation
Classification of malnutrition disorders
A- Protein energy malnutrition:
- Kwashiorkor - Marasmus
B- Vitamins and minerals deficiency:
Vitamins D ……… Infantile Rickets and infantile tetany
Vitamins C ……… Scurvy.
Minerals ………Iron deficiency anemia, Iodine deficiency.
Consequences of malnutrition (long term effects)
1- Slowed growth & delayed development
2- Difficulty in school
3- High rates in illnesses

4- Social stress

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 Types of protein energy malnutrition
Marasmus

Definition:
Marasmus is a state of chronic under nutrition caused by deficiency of all
food groups. It is characterized by failure to gain weight, followed by
progressive loss of weight reaching below 60% of the normal.
Incidence:
Commonly to occur in children under age one year.
Etiology:-
1-Dietetic errors:
-Small amount of feed -Widely spaced feeds
-Delayed weaning -Diluted formula in artificial feeding.
2-Gastroenteritis: recurrent acute attacks or chronic gastroenteritis.
3- Infections: repeated acute or chronic infections such as TB, measles.
4-Parasitic infestations: Ankylostoma, Ascaries, Giradia.
5-Malabosportion syndromes
6-Some cases mental retardation
7- Congenital anomalies
8-Prematurity due to poor suckling and less mature GIT.
9- Socioeconomic causes due to ignorance, poverty and deprivation.

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Clinical picture of marasmus
1- Failure to gain weight then loss of weight, body weight less than 60%
of normal with no edema.
2- Loss of subcutaneous fat (SC) which is classified into degree:
1st degree : Loss of s.c fat from the abdominal wall, 2nd degree : Loss of
s.c fat from the abdominal wall, buttocks, thigh and limbs. 3rd degree :
loss of s.c fat in the abdominal wall and limbs and face

3rd degree 2nd degree 1st degree

3- Senile facies.
4- Skin manifestations include loss of skin elasticity, skin show multiple
folds especially at the groins, visible peristalsis due to thin abdominal
muscles and irritability due to hunger pains, there is decreased muscle
bulk which is evident by decrease mid arm circumference.
3- Muscle wasting (thin muscles and prominence of bony surfaces)
4- GIT manifestations which include constipation due to decreased food
intake and diarrhea occurs in gastroenteritis, maldigestion and
malabsorption.
5- Weak and slow pulse, in case of dehydration lead to weak, rapid pulse,
peripheral circulatory failure in the end stage and the respiratory system
shows shallow rapid respiration due to weak respiratory muscles.
7- Hypothermia occurs due to decrease of caloric intake, loss of SC fat
lead to increase heat loss.
8- Hypovolemia and Hypoglycemia.
9- Liability to infection due to impaired immunity.
10- Hunger

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11-Anemia
Complications of Marasmus
Intercurrent infection: Broncho pneumonia is the cause of death Gastro
enteritis
Hemorrhagic tendency
Hypothermia
Hypoglycemia
Heart failure due to anemia and infection.
Treatment
1- Prevention :-
- Proper diet (balanced nutritional diet).
- Encourage breast feeding up to weaning.
Proper weaning.
Teaching about nutritional needs.
-Proper vaccination as measles, T.B. whooping cough.
-Education regarding the cheap sources of balanced diet, family planning.
- Proper follow up of the child growth .
- Early treatment of defects or diseases
2 – Curative treatment:-
A- Proper dietary management:-
Adequate balanced feeding. teaching about nutritional needs. preparation
of diet, technique of administration of food
If there is vomiting give IV fluids or naso gastric tube feeding.
Gradual increase the amount and concentration of formula.
B – Treatment of the cause
C- Emergency treatment for complications
D – Blood transfusion
E – Vitamins and minerals supplementation

Kwashiorkor
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It is a form of malnutrition characterized by slow rate of growth due to
deficient of protein intake, vitamins & minerals deficiency and high CHO
diet (adequate supply of calories).
Incidence
Commonly to occurs in children ages one to three years, It tends to occur
after weaning when children change from breast milk to diet consisting
mainly of CHO.
Etiology:-
1- Poverty and ignorance lead to giving unbalanced diet
2- Faulty weaning practice when the 2nd one is born lead to the 1st one is
suddenly weaned on CHO diet.
3- Faulty management of marasmic child, by giving them carbohydrate
diet only.
4- KWO resulting from other diseases, which are usually predisposing
factor rather than actual causes, these are infections as infective diarrhea,
this lead to defective food absorption, measles that causes difficulty of
oral feeding and sore throat, maternal deprivation due to birth of another
infant and prolonged dietary restriction .
Clinical manifestation
1- Constant features
I-Growth retardation

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Start by failure to gain weight then there is loss of weight. Loss of weight
is masked by edema and lead to moon face baby.
2-Edema
Edema which is pitting soft, painless and bilateral starts in the dorsum of
the hands and dorsum of the feet. Then it spreads to affect the legs up to
mid thigh, in late cases it affects eyelids. There is no ascites, edema
occurs when serum albumin is below 2.5 gm% (N=4-6gm%).

3- Mental changes
Mental changes include apathy, restlessness, sluggish movement and
disinterest in the surroundings.
II - Variable feature: Some of these features may be present or not.
1-Skin changes:
- Skin usually shows erythema and hyperpigmentation, followed by
desquamation and ulceration may occur due to secondary infection.
- Fissuring and cracking of the skin around angle of the mouth, it
becomes easily bleed.
2- Hair changes
-The hair losses its luster, becomes easily pickable and sparse.
-The color changer into dark brown, light brown, red, yellow or even
white.

174
- Hair changes are due to deficiency of sulphur containing amino acids,
deficiency of cupper and decrease of vitamin A.
3- Gastrointestinal disturbance (anorexia, vomiting, diarrhea and
abdominal distension due to diarrhea, weak abdominal muscles, infection,
malabsorption and infestation).
4- Enlargement of the liver may be present or not.
5- Anemia may be due to one of the following factors (iron, vit B12 ,
protein) deficiency and infections.
6-Vitamins and minerals deficiency.
Complications of kwashiorkor
1- Interrcurrent infections: respiratory, GIT, UT, skin.
2- Gastroenteritis: leading to dehydration, electrolyte and acid base
imbalance.
3- Hypoglycemia.
4- Hemorrhagic tendency
6 - Heart failure due to anemia and infections.
Investigations for Marasmus and kwashiorkor
1-Blood analysis: (W.B.C,Electrolytes, Glucose (hypoglycemia),ketones,
Albumin, total protein, amino acids, Enzymes, k (hypokalemia)
2-Urine analysis, culture for infection
3-Stool analysis for parasites
4-Chest x-ray
5-Tuberculin test
Treatment of kwashiorkor
A-Prevention
- Proper diet (balanced nutritional diet).
- Encourage breast feeding up to weaning.
- Proper weaning.

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- In weaned infant and young children prescribing high protein diet is
important. Milk should be given twice daily other high protein foods as
yogurt, cheese, liver, vegetable soup, chicken, fish, meat and eggs. Cheap
protein diet, legumes as cottage cheese, beans, lentil and other legumes
- Education regarding the cheap sources of balanced diet and family
planning.
- Proper vaccination for communicable disease as measles, T.B.
whooping cough.
- Follow up of the growth of the baby to early detect any deviation from
normal growth pattern.
B- Curative
1- Dietetic management:
- Diet should contain high protein diet and avoidance of sugar fluid, rice
water and starch pudding which are the main causes.
- Give 100-120 calories/kg/day, rich in proteins.
- Daily supplements of vitamin A (1500 I.U) can reduce mortality and
morbidity from respiratory infection and diarrheal disease. Iron (4-5
mg/kg/day) and folic acid (15 mg/d) are given to correct anemia.
- Treatment of the cause
2-Hospital management of severe cases:
- Hospital management is indicated in the presence of severe infections as
(pneumonia or severe gastroenteritis, severe water and electrolyte
disturbances as (dehydration and metabolic acidosis) also in case of
severe anorexia.
- Dehydration and electrolyte imbalance: Rehydration & correction of
electrolyte disturbances.
-Hypoglycemia; glucose 10% by IV drip
-Treatment of infections: when infection is suspected, appropriate
antibiotic therapy should be started immediately.

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-Transfusion therapy:
Whole blood transfusion may be indicated as life saving measure when
there is severe anemia (hemoglobin less than 6gm/100ml). Plasma
transfusion (10 ml/kg) or salt free albumin (5 ml/kg) is indicated in case
of severe hypoalbuminema.
- Vitamins and minerals supplementation
Common Nursing Diagnoses of Marasmus and KWO
Altered nutrition :less than body requirements related to knowledge
deficit, infection, emotional problems, physical deficit
Body temperature alteration (hypothermia) related to low subcutaneous
fat and deficiency of food intake
Impaired skin integrity related to vitamins deficiency
Fluid volume deficit related to diarrhea
High risk for infection related to low body resistance.
Role of the nurse
• Administer of blood and plasma transfusion as ordered.
• Administration of IV fluids and medication as ordered.
• Monitor intake and out put.
• Weight the child daily and record.
• Feed the infant orally by bottle or spoon. If not impossible through
nasogastric tube.
• Give feeding slowly and in small amount.
• Avoid interruption of feeding with other activities such as laboratory
test or radiologic investigation.
• Maintain skin integrity by:
Clean skin with clear water and apply oil if needed.
Care of the buttocks especially with diarrhea.
Frequent change position to prevent skin ulcer.

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• Protect the infant or child from infection by maintain the feeding
equipment sterile, avoid contact with patient or caregivers who have
infection.
• Maintaining the body temperature within a normal range by:
Place the infant in warm humified incubator, radiant warmer or warmly
clothed in open bed.
Dress the infant extra clothes.
Monitor hourly in unstable infants.
Avoid situation that might predispose infant to heat loss such as exposure
to cool draft, bathing.
• Health Teaching the family especially the mother about:
Adequate diet, proper weaning time and suitable food.
Parent should be encouraged to continue interventions began in hospital.

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 Difference between Marasmus and KWO
Marasmus KWO
Definition is a state of chronic Deficient of protein
malnutrition caused by intake, vitamins &
deficiency of all food minerals deficiency and
groups high CHO diet
Incidence Commonly to occur in Commonly to occurs in
children under age one children between ages
year. one to three years
Signs and symptoms (features)
Growth Failure Present Present
Muscle wasting Sever Muscle wasting Mild or absent
Edema Absent Present
Face Senile face or old man Moon face
Subcutaneous fat (SC) Absent Reduced
Skin dry, wrinkled and no Dermatitis, erythema
dermatitis and hyperpigmentation
Hair change Absent losses its luster,
becomes easily pickable
and sparse.
Appetite Good Poor
Albumin Low Very Low
Fatty liver Uncommon Common
Response to treatment Good Poor
Diet Need adequate amount Need adequate amount
of protein, fat, CHO, of protein, vitamin and
vitamin and minerals minerals.

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 Vitamin and mineral deficiencies

Infantile rickets

Definition: It is a deficiency disease affecting the skeleton of growing

children due to lack of vitamin D.

Etiology

1- Nutritional: Insufficient dietary intake of Vit –D.

2-Insufficient exposure to sun ray (ultra violet rays).

3-Other causes of deficiency include:

-Malabosrption of vit D .

-Deficiency of the active form of vit D as in chronic renal disease,

anticonvulsant drugs, hepatic disease.

Predisposing factors

1- Age: most commonly in infants 6m-2y. of age (due to rapid rate of

growth)

2- Heredity: dark skin contribute the effect of ultra violet rays

3- Season: more in winter and early spring

4-Atmospheric conditions: more common in big cities due to presence of

dust, smoke, glass windows preventing UVR, in addition more
prevalence of artificial feeding.

Clinical manifestations

Appearance of the head:*

-The head appears enlarged and square

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-The anterior fontanel is delayed in closing.

-The cranial bones are soft make a cracking sound under pressure, this
condition is called craniotabes.

*Thorax

Pigeon chest (sharp protrusion of the sternum).-

-Shows the rachitic rosary beading of the costochondral junctions.

-Harrison's groove ( bilateral depression at the sites where the diaphragm

is attached to the ribs).

-When the infant is old enough to sit a dorsal kyphosis develops.

Extremities *

-Bowlegs or knock knees accompanied with flat foot.

- There is epiphyseal enlargement of the wrists and ankles.

* Relaxation of the abdominal muscles and may cause the child to be

constipated.

*Infant delayed in sitting, standing and walking due to poor muscular

tone.

Treatment of Infantile rickets

A-Prevention:

1- Exposure to UVR, the child should exposed to the sun shin before
11am and after 3 pm
2- Supplementation of the diet with daily requirements of vit D, 400-
800 IU/day. This can be in the form of cod liver oil, liver and egg
yolk.

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 3- Premature babies should receive 800-1200 IU as early as 2nd and
4th month of life.
B-Active treatment:

1- Vit-D: 1500-5000 iu/day for two months

2- oral calcium intake should be increased in conjunction with vit-D.

3-After complete healing, vit D should be given in a dose 400-800

IU/day.

4- Surgical correction of severe deformities.

5-Treatment of complication as tetany & deformities.

Role of the nurse

Ricketic children's back should be supported.-

Ricketic children's should be handled gently and turned frequently.-

-Avoid pressure on the infant, e.g. diaper should be applied loosely.

Ricketic children's must lie on firm matters to avoid deformity.-

Prevent infant's falling.-

-Explain to the mother the treatment of rickets so that she helps in his
care.

Infantile tetany

Tetany of infants occurring usually in association with rickets, due to

dietary deficiency of vitamin D

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Clinical manifestation

There are 2 stages in tetany manifest and latent

A- Manifest tetany: (serum calcium is less 7mg/dl).

1-Caro pedal spasm 2-Laryngeal spasm.

3-Generalized convulsions are commonly manifested in infants and

newborns.

B-Latent tetany: (serum calcium between 7-9 mg/dl) but no obvious

symptoms other than muscular irritability.

Treatment

1-Immediate: calcium gluconate 10% solution 5-10 ml by slow IV inj.

2-Colvusion may be controlled by oxygen therapy, ca gluconate IV and

sedatives.

3-Maintenance:

Oral calcium chloride 3-6 gm daily, diet should be rich in ca.

Role of the nurse

-Observation for signs of laryngospasm, such as stridor, hoarseness and

feeling of tightness in the throat.

Intubation equipment should be ready.-

Administration of medication as ordered.-

-Discuss with parents the child's need for continuous daily administration
of calcium salts and vit D.

Encourage and help parents participate in their child's care. -

-Advice parents to watch for signs of vit D toxicity (weakness, fatigue,

headache, nausea, vomiting and dia

183
 Anemia

Prepared by

Dr. Azza Elewa

184
Outline
Definition of anemia
Classification of anemia
Signs and Symptoms of anemia
Investigations of anemia
Management of anemia
Iron deficiency anemia
Thalassemia
Sickle Cell Anemia
Definition of anemia
Anemia in childhood is defined as a hemoglobin (Hb) concentration
below established levels. These levels vary depending on the age of the
child and gender.
Classification of anemia
Anemia can be classified in a variety of ways, based on the morphology
of RBCs and etiologic mechanisms.
1-Etiologic classification
a-Decreased or impaired red blood cell (RBC) production caused by:
- Chronic disease as renal failure, endocrine disorders
-Disturbance of proliferation and maturation of RBC as vitamin B12
deficiency , folic acid deficiency, iron deficiency.
-Resulting in deficient heme synthesis as thalassemia, renal failure
-Other mechanisms of impaired RBC production as resulting from the
replacement of bone marrow by other materials, such as malignant
tumors.
b-Increased destruction (hemolysis)
Anemia of increased red blood cell destruction are generally classified as:

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•Intracorpuscular abnormalities caused by:
-Red blood cell Enzyme defect as Glucose-6-phosphate dehydrogenase
deficiency
-Hemoglobin disorder as Sickle cell anemia, thalassemia
• Extracorpuscular abnormalities:
-Autoimmune: the body produces antibodies that destroy the red blood
cells. It can be idiopathic or secondary to another disease such as
systemic lupus erythematosus, or malignancy, such as chronic
lymphocytic leukemia .
-Isoimmune (e.g)
Rh disease , reaction to blood transfusions
-Nonimmune (e.g) drug-associated, Heart surgery, Infections,
Haemodialysis
Blood loss caused by::
•Trauma or surgery, causing acute blood loss
• Gastrointestinal tract lesions, causing either acute bleeds (e.g. peptic
ulcers).
Fluid overload
Fluid overload (hypervolemia) causes decreased hemoglobin
concentration and apparent anemia.
Morphologic classification
1-Microcytic: It means decrease the red blood cell size (mean
corpuscular volume)
Microcytic anemia is primarily a result of hemoglobin synthesis
failure/insufficiency, which could be caused by several etiologies:
- Iron deficiency anemia -Alpha and beta-thalassemia

- Chronic infection -Lead poisoning

2-Macrocytic:it means increasethe red blood cell size.
Macrocytic anemia occur as a result of:
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-Deficiency of either vitamin B12, folic acid
-Hypothyroidism
-Liverdisease.
-Drugs such as Methotrexate
3-Normocytic
Normocytic anemia occurs when the overall hemoglobin levels are
decreased, but the red blood cell size (mean corpuscular volume) remains
normal. Causes include:
•Acute blood loss •Anemia of chronic disease
•bone marrow failure •leukemia
•Hemolytic anemia •Chronic renal failure
Symptoms of anemia
•Easy fatigue and loss of energy•Rapidheart beat
•Shortness of breath • Headache.
•Difficulty concentrating•Dizziness
•Legcramps• Loss of appetite
Signs of anemia
Pallor , yellow
Tachycardia, cardiomegaly
Low blood pressure
Skin moist and cold
Weight and height can be affected in chronic anemia.
Petechiae and bruising
Splenomegaly
Investigations
• Full blood count and blood film.
• Reticulocyte count.
• Hemoglobin electrophoresis.
• Red cell enzyme studies

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• Iron, ferritin and total iron binding capacity levels.
• Other diagnostic tests, such as bone marrow biopsy, can show specific
causes, for example marrow tumor cells
Management
Management depends on the underlying cause. Blood transfusion is only
required in severe cases.
Iron deficiency anemia
It is the most common cause of anemia occurs result of inadequate intake
or excessive loss of iron.
Causes include:
-Low intake of iron.
-Impaired absorption of iron from diets.
-Blood loss.
- Increased body need for iron as period of life when iron requirements
are high (i.e during growth).
- Parasite infections such as ascaris and schistomiasis lead to blood loss.
-Infectious diseases such as malaria, HIV and tuberculosis .
-Economic factor, a caregiver knowledge deficit about nutrition.
Signs and Symptoms
-May be asymptomatic
-Fatigue, Headaches, Coldness in the hands and feet
-Shortness of breath
-Failure to thrive
-Poor concentration.
-Tachycardia, cardiomegaly and hepatomegaly are signs of congestive
cardiac failure.
-Pallor affecting the skin and mucous membrane.
-Petechiae and bruising.
-Splenomegaly .

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Diagnostic Tests
-Complete blood count values reveal low red blood cell count, low
hemoglobin, and low platelet counts. Low mean corpuscular volume
(MCV).
- Reticulocyte count: normal or slightly reduced.
- low serum ferritin, a low serum iron level
Treatment
-Prevention by maintaining adequate nutrition.
- Manage the underlying causes
-Mild to moderate iron-deficiency anemia is treated by oral iron
supplementation.
-Iron supplement with milk or iron-fortified cereal by age 4 to 6 months
-Supplemental iron intramuscular or intravenous.
-Vitamin B12 supplement
- Vitamin C supplement
-Packed red blood cells in severe cases
-Oxygen supplement if severe hypoxia noted.
Nursing Intervention
- Monitor vital signs for signs of circulatory or respiratory distress due to
low blood levels and poor oxygenation.
-Administer oral iron as ordered.
-Inform family of dietary sources high in iron such as green leafy
vegetables.
-Administer vitamin C to enhance absorption.
- Avoid substances that impair absorption (tea).
-Caution family that stool will be dark green to black due to iron intake.

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 Thalassemia
Thalassemia is genetic blood diseases that vary widely in severity from
mild to severe anemia in which the hemoglobin production is abnormal,
involving decreased and defective production of hemoglobin.
Hemoglobin contains two different kinds of protein chains named alpha
and beta chains. There are two types of thalassemia: alpha-thalassemia
and beta-thalassemia.
Thalassemia passed down from parents to children (genetic). If only one
parent passes the gene for thalassemia to their child, then the child is said
to have thalassemia trait.. In other cases, the child gets a gene for
thalassemia from both parents and has a more severe form of the disease.
Alpha-Thalassemia
There are four genes that control the production of alpha globin. The
severity of the condition is determined by how many of these genes are
missing or abnormal. Alpha-thalassemia can range from mild to severe.
Categories Alfa thalassemia
•Silent carrier, the mildest form, has one alpha globin gene missing or
abnormal. Affected child generally have no symptoms, but they can pass
on the genetic abnormality to their children.
• Minor Alpha thalassemia (also called alpha thalassemia trait) has two
missing or abnormal alpha globin genes. Affected child may have no
symptoms or a mild anemia, but they can pass the condition on to their
children.
• Moderate Alpha thalassemia
Is caused by three missing or abnormal alpha globingenes. Signs and
symptoms will be mildto moderate.
•Major Alpha thalassemia or or hydrops fetalis
The most severe form, is caused when there are no alpha globin genes.

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This almost always leads to a fetus dying before delivery or a newborn
baby dying shortly after birth.
Beta -thalassemia
Categories beta thalassemia
Beta -Thalassemia disorder is grouped into three categories: thalassemia
minor (trait), intermedia, and major (Cooley's anemia).
Beta Thalassemia minor (trait)
Thalassemia minor often goes undiagnosed because children have no real
symptoms. No treatment is needed.
Beta Thalassemia intermedia
Produce moderate anemia and they might require blood transfusions,
especially during other health problem or illness.
Beta Thalassemia major (Cooley's anemia)
This is a severe condition in which regular blood transfusions are
necessary for the child to survive. Without transfusions every few weeks,
children diagnosed with thalassemia major would usually die by age
7years due to the effects of severe anemia.
Signs and Symptoms of Thalassemia
• Pallor. Fatigue. Poor feeding.
• Hypoxia, headache, irritability and bone pain, decreased exercise
tolerance, Listlessness, Anorexia
• Bronzed skin: may be noted due to excess iron storage in the body.
•Poor growth may occur as a result of low hemoglobin and reduced
ability of the blood to carry oxygen to the body.
•Bone abnormalities such as enlargement of their cheek bones, foreheads,
flat or depressed nose and bone pain
•Jaundice or the liver and the spleen may be enlarged.
•Heart failure and infection.

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Diagnostic tests
• Hemoglobin electrophoresis analyzes.
•Complete blood count.
•Family genetic studies can show whether a child has any form of
thalassemia.
•Newborn screening tests to identify babies with thalassemia.
•Prenatal testing using amniocentesis can detect or rule out thalassemia in
the fetus.
Treatment for thalassemia
*Treatment for thalassemia is supportive.
-Blood transfusions every two to three weeks to treat beta thalassemia
major.
-Iron chelation (iron-removing) therapy is essential especially in high
transfusion programs, to prevent liver and heart damage.
a)Desferal is given by IV, IM, SC injection.
b) Oral iron chelating drug.
-Iron concentrations in the body are monitored every few months.
-Removal of the spleen may also be recommended .
-Daily folic acid.
-Bone marrow transplants.
Nursing Intervention
Administration of blood transfusion as ordered by physician.
Provide nursing care for blood transfusion before, during and after
transfusion.
Administration of medication as ordered.
Monitor the child's vital signs.
Provide care to the child receiving IV fluids.
Monitor intake and out put.
Monitor the signs of infection as elevation of the body temperature.

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Administer of preventive immunization to decrease risk of infection.
Encourage the child to avoid activities that increase the risk of fractures.
Perform regular growth measurements.
Ensure adequate nutrition to promote growth.
Encourage child to eat a high protein and caloric diet.
Provide emotional support to child and family .
Provide an opportunity for them to express their concerns.
Provide parents with information about the disease and the treatment.
Provide written instructions on all aspects of care and complications.
Listen and encourage child and family to verbalize their feeling.
Answer question honestly and openly.
Introduce the family to other families of children with thalassemia.
Regular checkups of the vision and hearing.
Teach child and family about infections control measures, including
proper hand washing and aseptic technique for infusion.
Sickle Cell Anemia
Sickle cell anemia is a type of anemia. SCD is the genetic disorders
characterized by the production of sickle hemoglobin (HBs) and
hemolytic anemia.
Sickle red blood cells are stiff , sticky and block blood flow in the blood
vessels of the limbs and organs.
Child who have Sickle Cell Trait (SCT) inherit one sickle cell gene (―S‖)
from one parent and one normal gene (―A‖) from the other parent. This is
called sickle cell trait (SCT). Child with SCT usually do not have any of
the signs of the disease and live a normal life, but they can pass the trait
on to their children.
Sickle Cell disease (SCD) : It is inherited when a child receives two
sickle cell genes one from each parent.

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Signs and Symptoms of Sickle Cell Anemia
Some children have mild symptoms. Others have very severe symptoms
and often are hospitalized for treatment.
I-Signs and Symptoms of anemia as:
Shortness of breath, Fatigue, Dizziness, Headaches, Coldness in the
hands and feet, Pallor, yellow.
II-Signs and Symptoms related to Crisis episodes:
Factors that causes of sickle cell crisis are infection, dehydration,
hypoxia, trauma and general stress.
a -Vasoocclusion crisis (painful crisis): most common crisis due to
blocked blood flow from sickling, it leads to severe pain according to the
affected site:
Hand-Foot Syndrome: Swelling often occurs on the back of the hands
and feet and moves into the fingers and toes.
Chest Syndrome: Child who has this condition often has chest pain,
shortness of breath.
b-SplenicCrisis
Characterized by large quantities of blood pooled in the spleen. This
causes enlargement of the spleen .
Others Signs and Symptoms
Liver:jaundice and hepatic coma
Pulmonary Hypertension
Stroke: Stroke can cause brain damage or death.
Eye Problems such as damage the retinas. This damage can cause serious
problems, including blindness.
Kidney: renal pain, hematuria and impaired function
Complications :
1-Heart (cardiomegaly).

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2-Eyes: visual disturbance, possible progressive retinal detachment and
blindness
3-Gallstones: Child who has gallstones may have nausea (feeling sick to
the stomach), vomiting, fever, sweating, chills, clay-colored stools, or
jaundice.
4-Delayed Growth and Puberty in Children
5-Infection
Diagnoses of Sickle Cell Anemia
*New borne screening for SCD has significantly decrease the mortality.
*A laboratory diagnosis of SCD:
-CBC -Hemoglobin electrophoresis -Reticulocyte counts
-Diagnose sickle cell disease before birth. This is done using a sample of
amniotic fluid.
Treatment
The goals of treating sickle cell anemia are to relieve pain, prevent
infections, organ damage, and strokes and control complications.
Treatment include:
- Hydration to decrease sickling and vascular blockage.
- Blood transfusion.
-Electrolyte replacements to correct imbalances
- Oxygen supplement.
-Vigorous treatment of complicating bacterial infection.
-Immunization against infectious diseases.
-Bone marrow transplants may offer a cure for a small number of child
who have sickle cell anemia.
-Mild pain often is treated at home with prescribed medicines, heating
pads, rest, and excessive of fluids. More severe pain may need to be
treated in a day clinic, emergency room, or hospital.

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-Sequestration crisis treated by plasma transfusion and emergency
splenectomy may be indicated.
-Nursing diagnosis
-Ineffective tissue perfusion -Pain - Risk for infection
-Ineffective coping -Activity intolerance
-Altered growth and development
-Deficit of knowledge about the disease
Nursing intervention
Monitor the child's vital signs.
Administer oxygen to promote adequate oxygenation
Administration of adequate fluid to prevent dehydration, fluids are given
either by the mouth or the vein.
Monitor intake and out put
Administration of RBCs as ordered, to maintain adequate hemoglobin.
Administration the prescribed analgesics and monitor the effectiveness of
medication
Use appropriate nonpharmacologic pain relief measures to distract the
patient from discomfort, as relaxation and distraction. apply heat pads to
the affected areas.
Place the child in comfortable position and maintain adequate rest.
Encourage children to participate in appropriate activities and avoid
contact sports.
Monitor the signs of infection as elevation of the body temperature.
Administer of preventive immunization to decrease risk of infection.
Avoid known sources of infection.
Perform regular growth measurements.
Ensure adequate nutrition to promote growth
Encourage child to eat a high protein and caloric diet.
Provide parents with information about the disease and the treatment.

196
Provide written instructions on all aspects of care and complications.
Listen and encourage child and family to verbalize their feeling.
Answer question honestly and openly.
Provide parent with phone members of persons to contact if they
questions or problems.
Instruct parents it is important to inform all treating physicians and
dentists of the child medical condition.
Give instructions about the administration of medication and the side
effect.

Hemophilia
Hemophilia is a bleeding disorder caused by a problem in the blood
ability to form a clot. It is an inherited condition that present at birth.
Hemophilia is classified as mild, moderate or severe based on the level of
coagulation factor present in the blood. Child who is suggesting severe
hemophilia will usually bleed frequently. Whereas another child with
milder form will usually bleed only rarely.
Types of hemophilia
1- Hemophilia A: known as factor VIII deficiency.
2- Hemophilia B: known as factor IX deficiency.
3- Hemophilia C: known as factor XI deficiency.
Clinical manifestation
The following signs and symptoms may be present
Excessive bleeding induced by minor injury or trauma.
Prolonged bleeding from the wound.
Bleeding after circumcision or tooth extraction.
Hematuria. Epistaxis.
Hemarthosis, pain, swelling, bleeding occur in joint and muscles.

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Diagnostic test
Laboratory tests for clotting speed are used to confirm the diagnosis
includes:
Prothromin (prolonged).-
Partial prothrombin time.-
Bleeding time.-
Fibrinogen level and platelet count.-
Treatment
There is no cure for hemophilia. Treatment is done to stop or prevent
bleeding.
Treatment may include one or more of the following:
Bleeding is treated with rest, ice, apply pressure to the bleeding site and
elevation the affected site.
Fresh or fresh frozen plasma 10-15 ml/kg every 12 hours.
Factor VIII concentrate.
Prophylaxis treatment includes:
Avoidance of trauma, avoid aspirin .
Before surgery or dental extraction, plasma factor VIII activity should be
elevated.
Nursingintervention
Administration of medications as ordered.
Instruct child to soften tooth brush in warm water before brushing.
Avoid IM injection.
Avoidance of trauma, avoid aspirin.
Avoid rectal temperature measurement.
Observe child for swelling in the joints.
Promote rest, apply ice, pressure to the bleeding site and elevation the
affected site.

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Explanation about the disease, diagnosis, clinical manifestation and
complications.
Teach the family the need for safety precautions, administering of
medication and following treatment plan.
Listen and encourage the child and family to verbalize their feelings.
Introduce the family to other families of children with hemophilia.

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 Oncology
Introduction

In cancer, cells divide and grow uncontrollably, forming malignant

tumors and invade nearby parts of the body. The cancer may also spread
to more distant parts of the body through the lymphatic system or
bloodstream.

Different kinds of cancer have different signs, symptoms, treatments and

outcomes, depending on the type of cell involved and the degree of
uncontrolled cell growth. The most common childhood cancers are
leukemia, lymphoma and brain cancer.

Leukemia

Leukemia is cancer of the blood and develops in the bone marrow. The
bone marrow is the soft, spongy center of certain bones that produces the
three major blood cells: white blood cells to resist infection; red blood
cells that carry oxygen; and platelets that help with blood clotting and
stop bleeding. When a child has leukemia, the bone marrow, for an
unknown reason, begins to make white blood cells that do not mature
correctly, but continue to reproduce themselves.
These abnormal cells reproduce very quickly and do not function as
healthy white blood cells to help resist infection. When the immature
white blood cells, called blasts, begin to crowd out other healthy cells in
the bone marrow, the child experiences the symptoms of leukemia (i.e.,
infections, anemia, bleeding).

211
Causes leukemia in children
The exact cause of leukemia remains unknown, but there are may
include:
-Genetic factors
-Chromosome abnormalities.
-An alteration or defect in the immune system may increase the risk for
developing leukemia.
- Factors such as exposure to certain viruses, environmental factors,
chemical exposures, and various infections have been associated with
damage to the immune system

Different types of leukemia

There are three main types of leukemia, including the following:

 Acute lymphocytic leukemia (ALL)………………………………

It also called lymphoblastic or lymphoid. In this form of the disease,
the lymphocyte cell line is affected. Acute leukemia can occur over a
short period of days to weeks.
 Acute myelogenous leukemia (AML)……………………………..
It also called acute non lymphocytic leukemia (ANLL), granulocytic,
myelocytic, myeloblastic, or myeloid. It is a cancer affect the myeloid
cell of the blood and grow quickly.
 Chronic myelogenous leukemia (CML): is cancer of the blood affect
the myeloid and grow slowly, can occur over a period of months or
years.

Clinical manifestation of leukemia

Clinical manifestation may include:

211
Fever, pallor, bleeding and bruising, bone or joint pain (usually leg /knee
pain), malaise, anemia, recurrent infections.…………………… .
Abdominal pain, loss of appetite and weight loss, hepatosplenomegaly,
Swollen lymph nodes, difficulty breathing (dyspnea). The severity of the
clinical manifestation varies with length type of leukemia and the length
of diagnosis.……………………………………………………………….
Diagnosis of leukemia

In addition to a complete medical history and physical examination,

diagnostic procedures for leukemia may include:

 Bone marrow aspiration shows blast cells.

 Complete blood count (CBC) shows decrease Hb & RBCs count,
thrombocytopenia, leucopenia.
 blood chemistries, evaluation of liver and kidney functions and
genetic studies.
 Computed tomography scan.
 Ultrasound.
 lymph node biopsy.
 lumbar punctures.

Treatment for leukemia:

Treatment for leukemia may include one or combination of the following:

 Chemotherapy.
 Radiation therapy
 Bone marrow transplantation or peripheral blood stem cell
transplantation
 Medications (to prevent or treat damage to other systems of the body
caused by leukemia treatment)

212
 Medications (for nausea and side effects of treatment)
 Blood transfusions (red blood cells, platelets)
 Antibiotics (to prevent/treat infections)
 Continuous follow-up care (to determine response to treatment, detect
recurrent disease, and manage late effects of treatment)

There are various phases in the treatment, these are:

Induction

During the induction phase, chemotherapy medications are given.

Sometimes radiation is included .

The goal of the induction phase kill the leukemia cells in the blood as
well as their parent cells in the bone marrow .

Consolidation

Treatment is continued.

The goal of this phase is to kill off any remaining cancer cells

Maintenance

During the maintenance phase, less intense chemotherapy is given over a

long time .

This phase can last months to several years .

The goal of this phase is to prevent a relapse .

Regular visits to doctor are required to sure the treatment is working and
to check for any recurrent disease .

213
These visits are also needed to take care of any side effects of the
treatment.

Prognosis

Prognosis and long-term survival can vary greatly from child to child.
Prompt medical attention and aggressive therapy are important for the
best prognosis. Continuous follow-up care is essential for the child
diagnosed with leukemia.…………………………………………………
Nursing care plan for child with leukemia
Nursing diagnosis
-Risk for infection
-Risk for injury
-Altered nutrition less than body requirement.
-Body-image disturbance related to loss of hair.
-Impaired skin integrity related to administration of chemotherapeutic
agents, radiotherapy, immobility.
- Altered family processes related to having a child with a life-threatening
disease.
-Pain related to disease and procedures.
Goal
-The child will exhibit no signs of infection.

-Protect the child from injury.

- Child will receive adequate nutrition

- Child Will show positive coping behaviors

- Will maintain skin integrity.

-The child and family will:
Adhere to the treatment plan and follow up visits.
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Demonstrate knowledge about diagnostic/therapeutic procedures.
Receive adequate support.
Demonstrate knowledge about diagnostic/therapeutic procedures.
-Child will report lessened pain.
Nursing intervention

Place child in private room to minimize exposure to infective organisms.

Advise all visitors and staff to use good hand washing technique .

Use aseptic technique for all invasive procedures.

Monitor temperature.

Provide nutritionally complete diet for age .

Administer antibiotics as prescribed.

Teach child and family about infections control measures, including
proper hand washing and aseptic technique for infusion.

** Use local measures (e.g., apply pressure, ice) to stop bleeding.

Restrict strenuous activity.

Avoid IM injection to prevent bleeding.

Avoid taking rectal temperature, performing rectal examination .

**Encourage adequate nutrition
Encourage child to eat a high protein and caloric diet.
Offer small feedings. Weight daily.
Provide small frequent meal, provide food in an attractive ways.

**Introduce idea of wig before hair loss .

215
Encourage child to select a wig similar to child's own hairstyle and color
before hair falls out .

Explain that alopecia during a second treatment with same drug may be
less severe.

**Provide skin care, especially in mouth and perianal regions.

**Assess need for pain management

Implement appropriate nonpharmacologic pain reduction techniques

Administer analgesics as prescribed

**Explain reason for radiotherapy, chemotherapy, each test and

procedure.

Explain all procedures that will be done to child.

Teach parents about disease process.

Encourage family to discuss feelings .

Evaluation
-The child is free from infection.

-The child is free from injury

Nutritional intake is adequate, Child maintains admission weight.

Child exhibits no evidence of bleeding.

Child verbalizes concern regarding hair loss.

Skin remains clean and intact.

Child and family demonstrate understanding of procedures .

216
Family demonstrates knowledge of child's disease and treatments .

-Child pain reduced to level, Child rests quietly, reports or exhibits no

evidence of discomfort, and verbalizes no complaints of discomfort

Wilms' tumor

Wilms' tumor, also called nephroblastoma, is a malignant tumor

originating in the cells of the kidney. It is the most common type of renal
(kidney) cancer and accounts for about 6 percent of all childhood cancers.
The prognosis and long-term survival can vary greatly from child to
child, but most children with Wilms' tumor can be cured of the
disease.Wilms' tumor occurs in children up to about age 8 years.

Causes

Most cases of Wilms' tumor occur by chance. They are the result of
change in cells in the kidneys that usually occur after birth. In some
cases, however, a genetic defect increases the risk of Wilms' tumor.

Signs and symptoms of Wilms' tumor

 Abdominal swelling.
 Fever, Abdominal pain, Constipation.
 High blood pressure (hypertension).
 Blood in the urine (hematuria).
 Fatigue, Loss of appetite, Weight loss.
 Frequent urinary tract infections.
 Anemia with accompanying pallor, anorexia, and lethargy may be
noted.

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Diagnosis of Wilms' tumor

After taking a complete medical history and doing a physical

examination, the following tests ordered to look for spread of the cancer:

 Ultrasound: Identifies the size of the mass and the location of the
mass
 Bone scan.
 Abdominal computerized tomography scan (CT scan).
 Chest X-ray.
 Magnetic resonance imaging (MRI).
 Blood and urine tests to evaluate the liver and kidney functions.
 Biopsy.

Treatment for Wilms' Tumor

Treatment strategies for Wilms'tumor depend upon the stage of the

disease, treatment includes:

-Surgical removal of tumor and chemotherapy

-The involved kidney is surgically removed. In addition, lymph nodes

near the tumor are removed and evaluated for any evidence of cancer
involvement.
-Chemotherapy is currently recommended, regardless of the extent of
tumor involvement or results of the surgery.
-Chemotherapy to shrink tumor before surgery.
-The type and intensity of the chemotherapy is dependent on the stage of
the disease.

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-Radiation therapy is used in selected patients with more advanced
disease to shrink the remaining tumor or to treat metastasis and/or
recurrent disease.
-Medications are used to control pain, hypertension, nausea, and
infections.

Nursing management

Nursing management can be divided into 2 phases pre and post renal
phase and chemotherapy phase.

Preoperative care:

Avoid palpation to avoid metastasis.

Handle the child carefully during transportation and repositioning to

avoid rupturing the tumor capsule.

Frequent blood pressure measurements

Family-Centered Care:

Educate the child and family about the disease and operation.

Explain the symptoms that may result from preoperative radiation or

chemotherapy:

• Support child and family through diagnosis, treatment/surgery, and

follow-up care.

• Let family and child ventilate concerns and fears and provide emotional
support. Participate family in the care of the child.
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Prepare child for operation physically and psychology.

post renal phase includes:

Frequent repositioning the child.

Pulmonary hygiene, cough and deep breathing exercise.

Monitor intake and output.

Use of noninvasive and pharmacologic pain interventions to provide

comfort.

Daily weight. Gently handling of the child.

Observe the site of operation.

Monitor for complications: Bleeding, infection.

Genitourinary care and hygiene taken to prevent infection, monitor for

signs of infection.

Play therapy should include age appropriate activities to entertain and

distract child.

During chemotherapy

Close attention is given to the side effect of medication.

Maintain skin clean and dry.

Avoidance infection.

211
 Communicable Diseases of
Children in Egypt

Prepared by

Assistant professor Dr. Azza Elewa

211
General objective
At the end of this module the student should be able to:
Identify, estimate and distinguish between different types of
communicable diseases.
Intended learning outcomes:
At the end of this module the student will be able to learn:-
1- Knowledge and understanding:
Define communicable diseases and the other terminology.
State the etiology for different types communicable diseases.
Recognize the mode of transmission.
Identify child at risk for communicable diseases.
11-intellectual skills:
Distinguish between different types communicable diseases.
Apply the role of pediatric nurse in the management of different types of
communicable diseases.
Plan nursing process for the child with communicable diseases.
111-professional and practical skills:
Evaluate the child through out the different stages of the disease.
Carry out the prescribed medication.

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Introduction:
Communicable disease is defined as an illness caused by an
infectious agent or its toxins, which can be transmitted directly or
indirectly to a well person. Communicable diseases are caused either by
bacteria or virus.
Sources of infection consist of man, animal, contaminated food or
water, insects and environmental factors, such as, dust and dirt.
Incidence:
More common in pre-school and school-age children due to their
exposure to environmental condition unlike those at home.
Definitions of Terms:
Incubational Period:
Is the period of time between the invasion of microorganism and the
appearance of signs and symptoms of disease.
Communicability Period:
Time during which the infected person can transmit the disease
directly or indirectly to another person.
Mode of transmission:

The way (direct or indirect) by which an infectious agent is

transmitted from the reservoir to susceptible human host.

Direct contact: actual contact with the infected person.

Indirect contact: contact with the contaminated object.

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Common Communicable Diseases Caused by Bacteria:
1. Diphtheria
Etiology:
Corynebacterium diphtheria (Diphtheria bacillus).
Incubational Period:
2-6 days or longer.
Communicability Period:
Several hours before onset of the disease until organism disappear
from the respiratory tract.
Mode of Transmission:
Droplet from respiratory tract of an infected person or a carrier
directly or indirectly.
Clinical manifestation:
A child with diphtheria usually seeks medical help for one of the
following complains (sometimes they are called types).
1-Sore throat:
-Fever. -Difficulty to swallow. -Swelling of the
neck.
-Exudates or a white or grayish membrane on tonsils and may be
the pharynx. (Membrane varies from thin to thick one).
2-Croup:
-Hoarse , croupy cough and stridor.
-Noisy respiration, the child may have severe respiratory distress.
3-Nasal discharge:
-Purulent, bloody nasal discharge.
4-Other sings and symptoms:
That could be present (especially in severe cases):
-Purulent conjunctivitis.
-Otitis media. -Ulcerative vulvo-vaginitis.

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Nursing Care:
1. Isolate the child (place him in isolating room, use medical
aseptic techniques). Keep the child in isolation until 2
consecutive nose and throat culture are negative (24 hours apart
between the two cultures).
2. Bed rest for about 6 weeks.
3. Provide soft diet and fluids.
4. If nothing is taken by mouth, give IV solution, inserting
nasogastric tube and feeding child through it if required.
5. Administration of prescribed medication.
6. For fever: check vital signs, use 2-3-4 hours schedule; depending
on the degree of fever.
7. Observe: vital signs, secretion and the need for suction.
8. Tracheostomy and /or intubation trays must be ready at bedside
table of the child. If tracheostomy or intubation is done, apply
the proper care of tracheostomy or intubation.
9. In intubation, the child can expel the tube when he coughs, so
watch constantly as he can’t call for help. Frequent suctioning of
the tube use proper restraints so that he will not remove the tube.
10.Oral hygiene by warm water wash.
11.If myocarditis appears as a complication, guard the child for
exhaustion, beside the other nursing care.
Treatment:
1-Bed rest. 2-Antibiotics. 3-Anti-toxins.
Prevention:
1. Active immunization: DPT vaccine.
2. Passive immunization: injection with anti-toxins.
Complications:

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1-Bronchopneumonia. 2-Kidney dysfunction.
3-Paralysis. 4- Myocarditis. 5-Cardiac
failure.

2. Pertussis (Whooping Cough)

Etiology: Gram-negative bacillus (bordetella pertussis).
Incubation Period: 5-21days.
Communicability Period: 4-6 weeks from the onset of the disease.
Mode of Transmission: Droplet (direct and indirect).
Clinical manifestation:
Three stages:
a-Catarrhal stage: (coryza or prodormal stage)
It lasts 7-14 days.
-Mild fever, headache, anorexia.
-Persistent cough with tearing. -Sneezing.
b-Paroxysmal stage (Spasmodic or whooping stage):
Lasts 14-28 days (2-4 weeks).
-Paroxysmal cough develops. It is characterized by several
sharp coughs in one expiration, followed by one deep
inspiration, which may be accompanied by a whoop. Cough is
worse at night, interferes with sleep and frequently causes
vomiting.
-With cough, face becomes flushed and in some instances
cyanosis and dyspnea might occur.
-Anorexia. -Lymphocytosis occurs.
c-Convalescent stage:
It lasts 21 days. Cough and vomiting become less.
Nursing Care:
1. Isolation: Disinfection all utensils.

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 2. Bed rest: keep the child in bed in a well ventilated room.
3. For paroxysmal stage: Provide;
-Calm atmosphere to avoid emotional swings as laugh and cry
causing coughing attacks.
-Avoid dust in the room.
-Oxygen with humidity to relief cyanosis.
4. For vomiting:
-Raise head and shoulders of older children to avoid aspiration
of vomitus. .
-Mouth care.
-Small frequent feeding.
-Refeed the child immediately after vomiting.
-Accurate intake and output must be kept.
5. For anorexia:
-High caloric soft diet. Encourage the child to eat.
-Weight the child daily.
6. Observe: respiratory distress and convulsions.
7. Observe signs and symptoms of airway obstruction e.g.
restlessness, cyanosis, retraction.
Treatment:
 Symptomatic: sedatives and antispasmodics are important.
 Antibiotics are effective if given early (Ampicillin and
Erythromycin).
Prevention:
 Active immunization: DPT vaccine.
 Passive immunization: Gamma Globulin.
 In exposed immunized children, give an immediate booster
dose of pertussis vaccine.

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Complication:
 Otitis media.  Marasmus.
 Bronchiectasis.  Encephalitis.
 Hemorrhage may occur.  Pneumonia.

3. Tetanus(Lock Jaw)
Etiology: Clostridium tetanti (tetanus bacillus).
Incubational Period: 3-21 days.
Communicability Period:
Not communicable from man to man, as the organism usually live in
animal’s intestinal tract.
Mode of Transmission: Through a wound as organism is present in soil.
Clinical manifestation:
 Onset of the disease is either gradual or acute.
 Convulsions are the first warning symptoms in children.
 Excessive irritability and restlessness.
 Difficulty in swallowing.
 Stiff neck.
Within 24-48 hours, the muscular stiffness progress:
1. Trismus i.e. tight jaw, inability to
open the mouth.
2. Stiff arm and legs, then entire stiffness
of the body.
3. Swallowing usually becomes
impossible.
4. Resus sardonicus due to spasm of
facial muscles.
5. Opisthotonos, i.e., backward arching
of the back

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 6. These ongoing tetanic spasms lasts
about 10 seconds and occurs
following a slightest stimuli, such as,
claming the door or bumping the bed.
 Dyspnea and cyanosis can develop.
 Fever 38.5 -40°C.
 Constipation may develop.
 Lumbar puncture reveals increase reveals increase spinal
fluid pressure.
Nursing Care:
1. Isolation.
2. Protect the child from any stimuli (auditory or tactile
stimuli), so place the child in dark, quite room and
minimum handling.
3. If dyspnea and cyanosis are present, give oxygen.
4. For tetanic spasm:
 Protect the child from falling.
 The nurse must be alert for number, duration and
frequency of convulsion (in relation to sedation
administered).
 Record any change in trismus or inability to
swallow.
5. For inability to swallow:
 I.V. therapy for nutrition and
fluid balance.
 Gavage feeding may be ordered.
So, the nurse must report if
insertion of the tube causes
convulsions.

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  Accurate intake and output chart
is necessary.
 Mouth care if he can open his
mouth.
6. For constipation, give enema.
7. Check vital signs carefully.
8. If tracheostomy is performed; care of tracheostomy.
9. Naso-pharyngeal suction is done frequently.
Treatment:
1-Antibiotics (Penicillin). 2- Antitoxin. 3- Tranquilizers.
Prevention:
1. Active immunization: DPT vaccine.
2. Passive immunization: Injection of tetanus immuno-
globulin or antitoxin (a few hours after a wound
occur).
Complication:
1-Anoxia. 2-Atelectasis. 3- Pneumonia.

4. Scarlet Fever
Etiology:
Streptococcus pyogeneous. (Beta hemolytic streptococcus group A).
Incubational Period: 1-7 days.
Communicability Period: From onset to recover.
Mode of Transmission: Droplet infection, direct and indirect.
Clinical manifestation:
A-Prodromal signs:
1-Vomiting. 2-Headache 3- Rapid pulse
4-High fever then it drops when rash appears.

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5-Tongue: white tongue coating desquamates and red strawberry
tongue results.
6-Tonsils are red, enlarged and may have a patchy whitish
exudates on their surface.
B-Rash
Rash appears within the first 5 days of the disease. The rash will
be all over the body but not on the face. The chest and back are
affected first, and then the rash moves down-wards involving the
legs last.
 Distinct odor of the skin.
 Desquamation i.e., peeling of the skin. It starts at the top of
the body and proceeds downwards.
Nursing Considerations:
1. Isolation.
2. Bed rest for 12 days and good ventilated room.
3. Keep patient warm, dry and comfortable as possible.
4. For the distinct odor which associates with scarlet fever:
daily bath and change linen frequently.
5. For skin:
- Lubricate skin well with oil (daily) as Dr. order.
- Protect skin under and around the nose and lips with ointment.
(When nasal discharge is constant).
6. Nasal aspiration by gentle suction.
7. If the child is less than 2 years, elevate head and shoulders
to prevent danger of otitis media.
8.Accurate intake and output chart is important.
9. Diet in the first week: High caloric liquids then soft diet.
Avoid irritant liquid juice ―citrus‖.

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10. If there is pain in cervical lymph nodes, treat with heat in
the form of hot packs or cold according to doctor’s order.
11. Observe for complications.
Treatment:
1-Bed rest 2 - Penicillin. 3-Diet. 4 - Sedatives for pain.
Prevention:
No immunization.
Complication:
1-Rheumatic fever. 2-Glomerulo-Nephritis. 3-Pneumonia.

Communicable Diseases Caused by Virus:

1-Chicken Pox (Varicella)
This is a highly communicable disease in children.
Etiology: Virus [Varicella- Zoster- Virus (VZV)].
Incubational Period: 10-21 days (2-3 weeks).
Communicability Period:
One day before and six days after the appearance of the first vesicle.
Mode of Transmission: direct or indirect.
Clinical manifestation: Onset is sudden with:
Prodromal Stage:
1-Mild or light fever. 2-Anorexia. 3-Headache.
Acute Phase:
1-Rash: Successive crops of macules, papules, vesicles, crusts
(vesicles heals by forming the crusts by the end of the two
weeks). (Acute Phase).
2-Rash is itchy.
Nursing Care:
1-Isolation:
-Use medical aseptic technique.

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-Nasal and oral discharge, cloths and linens are currently
disinfected.
-Keep the child in isolation until all crusts disappear.
2-For rash (lesion):
-Cleaning the skin according to doctor’s order once or
twice daily. Cool sponge bath without soap.
-Change child’s clothes and bed linens daily to prevent
skin infection.
- For itchy lesions, nails must be cut and cleaned to prevent
skin scratching.
-Restraints may be needed to control scratching.
-Observe the skin lesions, change in appearance and it must
be recorded.
-If lesions in mouth, mouth wash.
-If lesions in genital organ, apply cold compresses.
3-For fever:
-Check vital signs and record it, especially
temperature.
4-Observe for complications and report immediately to the
doctor.
Treatment:
-No specific treatment.
-To relieve itching, calamine lotion, antihistamine and local
ointment are prescribed.
-Antibiotics for secondary infection.
-Don’t give aspirin due to high risk of Reye syndrome.
Complication:
-Abscess. -Encephalitis. - Glomerulonephritis may
occur.

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2-Measles (Rubella)
Most cases occur before adolescent and it occurs more in spring
months.
Etiology: Rubella Virus.
Incubational Period: 10-12 days (usually 10-20 days).
Communicability Period:
4 days before the appearance of rash to 5days after rash appearance.
Mode of Transmission: Direct or indirect.
Clinical manifestation:
a-Coryza: Primary symptoms which resembles common cold and
occur before rash appearance:
-Sneezing. - Dry cough
-Fever (range from 38.5 to 40°C, tending to be highest
just before the appearance of rash).
-On the 4th day, conjunctivitis and photophobia.
-Enlarged posterior cervical lymph nodes.
b-Koplik’s Spots: Are appear on day before rash. Whitish spots
resting on a reddish base appear on the inside of the mouth. They
can appear and disappear suddenly.
c-Rash: Rash appears on 2nd to 5th day and remain about a week.
-Appears first on face, behind the ears, on the neck,
forehead or cheeks. Then, spread downwards over the
rest of the body (trunk, arms, and legs).
-The rash is pinkish in color, begins with macular lesions
which progress to the popular type. Then, rash becomes
dark in color (brownish color on 5th day).
-Desquamation, which is find usually, follow the rash
appearance and then disappear.
-Rash is itchy.

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Nursing Care:
1. Isolation.
2. Bed rest: Occupy the child in bed after acute phase
with activities. Explain the reason for being in bed if
the child is old enough to understand.
3. For photophobia and conjunctivitis:
-Subduced light make the child more comfortable.
‖Dark room‖.
-Eye care with warm saline solution to remove
secretions or crust.
4. For fever:
-Measure the temperature carefully.
-Antipyretic as doctor’s order.
-Encourage fluids.
-Tapped compresses.
5. For itchy rash: Observe degree of itching and apply
lotion or ointment as doctor’s order.
6. For Koplik’s spots: Mouth care. Use gargle solution.
7. Treatment:
-Symptomatic. -Antibacterial therapy.
Prevention:
a-Active immunization: live attenuated vaccine.
b-Passive immunization:
-Newborn through the mothers while they were in uterus.
-Gamma-globulin.
Complication:
 Otitis media.  Lymphoadenitis.
 Tracheobronchitis.  Pneumonia.
 Imptiago,purpura.  Encephalitis.

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3. German Measles (Rubella)
Etiology: Virus.
Incubation Period: 14 to 21 days.
Communicable Period: During Prodromal period and for 5 days
after the rash.
Mode of Transmission:
1-Direct contact with nose and throat secretions of
infected persons.
2-Indirect via articles freshly contaminated with
nasopharyngeal secretion.
3-Trans-placenta congenital infection form infected
mother to the fetus.
Clinical manifestation:
Prodromal Stage:
-Mild fever (Disappear when rash appear).
-Slight malaise, headache and anorexia.
-Running nose, sore throat.
-Rash is faint macular rash. It is small pinpoint pink or pale
red macules which are closely grouped to look like scarlet
blush (botchy), which fades on pressure. ―It begins on face
and hairline move to trunk then extremities‖.
-Rash disappears in 3 days.
-Swelling of posterior cervical and occipital lymph nodes.
-No Koplik’s spots or photophobia.
Nursing Care:
1-Isolation especially form pregnant women.
2-Bed rest until fever subsided.
Treatment: Symptomatic.

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Prevention:
a-Active immunization; live attenuated rubella virus vaccine.
b-Passive immunization: Gamma- globulin.
Complication:
-Fetus damage if mother contacts the disease during pregnancy.
-Newborn may have congenital anomalies, such as deafness,
mirocephaly, mental retardation.
-Encephalitis.
4. Mumps (infectious Parotitis)
Mumps is common in children 5-10 years. It is acute virus
infectious disease, which may involve, many organs but commonly
affects the salivary glands (mainly parotids glands).
Etiology: Virus (paramoxyvirus).
Incubational Period: 14-21 days.
Communicability Period:
One to six days before the first symptoms appears until the swelling
disappears.
Mode of Transmission:
Direct or indirect contact with salivary secretion of infected person.
Clinical manifestation:
1- Prodromal stage “Coryza”:
-Low-grade fever. -Vomiting. -Headache. -Malaise and
anorexia.
2-Acute Phase:
1-Pain in or behind ears and pain on swallowing or chewing.
2-Swelling and pain in glands (unilateral or bilateral), which
return to normal in 10 days.
3-Orchitis in males and mastitis in female adolescent may
occur.

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Nursing Care:
1-Isolation.
2-Bed rest until swelling disappears.
3-For fever: Encourage fluids and tipped compresses,
antipyretics.
4-For glands:
-Mouth care and gargle frequently.
-Apply hot or cold compresses for the swelling. Use ice bag
(watch weight of the bag in order not to increase the pain).
5-For Orchitis: Support scrotum, use cold compresses for 20
minutes, then, remove it for 30 minutes, then, reapply it for 20
minutes…etc.
6-For Mastitis: Breast support, use cold compresses.
7- Provide soft food and avoid food required chewing.
Treatment:
-Symptomatic.-Sedatives.
Prevention:
a- Active immunization: Live attenuated vaccine.
b- Passive immunization: Gamma- globulin.
Complication:
 Rare, sterility, Ovaritis, inflammation of testicles, Deafness.

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5. Poliomyelitis (infantile Paralysis)
It attacks the brain stem and spinal cord.
Etiology:
Virus, The disease is caused by any one of 3 polioviruses:
a- Type 1 (Brunhilde). b-Type 2 (Lansing).
C-Type 3 (Leon).
Incubational Period: 5-14 days.
Communicability Period:
3days after exposure to infection for 8 weeks from the onset of infection.
Mode of Transmission:
Oral contamination by intestinal and pharyngeal secretions of infected
person.
Clinical manifestation:
Severity of nerve involvement can vary from an absence of all clinical
signs of paralysis to complete paralysis. There are different possible
consequences of infection:
1-Inapparent Poliomyelitis: (Silent) No signs or symptoms
appears.
2-Abortive Poliomyelitis: Initial symptoms of upper
respiratory tract infection: fever, headache, vomiting…etc.
3-Non-Paralytic Poliomyelitis:
-Stiffness of neck, back and limbs.
-Nausea and vomiting become more severe than stage II.
-Fever. -Increase protein in C.S.F.
4-Paralytic Poliomyelitis: This may begin with manifestations
of the abortive or non-paralytic type. According to the neurons,
paralytic classified into:
paralysis appear within a day or two after the above
manifestations and 2-5 days from onset of the disease:

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 Paralysis of limbs is the most common affected muscles.
Muscles of the chest, abdominal wall, diaphragm, urinary bladder and
bowel can be affected constipation or stool incontinent and urinary
incontinent may occur.
More life threatening. It causes damage to cranial nerve nuclei, vital
centers of respiration, circulation and temperature control.
It may leads to swallowing problem and regurgitation of fluids from nose
and inability to swallow saliva, which puddles in the pharynx. If not
aspirated chocking may occur.
*Encephalitis:
manifestation include:
- Convulsion. -Personality disturbances.
Nursing Care:
1-Isolation and bed rest.
2-In acute stage:
-Put the child under close observation.
-Notify the doctor about the degree and progress of the
paralysis (7or8 days of the disease).
-Rate and type of respiration and signs of respiratory
distress must be observed and reported.
-Oxygen therapy or place the child on respirator when
cyanosis occurs.
-If tracheostomy is done in case of diaphragmatic
paralysis, care of tracheostomy.
3-For paralysis:
-Change position frequently. Careful positioning for
affected limbs each time he is turned or moved.
-To minimize the degree of deformity, correct body
alignment and optimum position must be maintained.

231
-Place the child on firm mattress.
-Use footboard to prevent foot drop when child is on
back. If the child is on abdomen, pull the mattress away
from foot of bed and letting feet protrude over the edge
to prevent pressure on toes.
-Application of heat to affected muscles to relax them.
4-Suction of the pharynx and postural drainage to prevent
aspiration of secretions.
5-For swallowing difficulties:
-Soft diet if they can swallow with difficulty.
-If swallowing is difficult, use gavage feeding.
6-For incontinent:
Skin care and perineal region is padded to provide
absorption for excretions. Catheter may be done.
7-For constipation: Use enemas.
8-Treat fever and headache.
Treatment:
-Symptomatic. -Physiotherapy.
Prevention:
a-Active immunization:
-Sabine: Attenuated virus, which is administered orally.
-Salk: Killed virus, which is administered by injection.
Note: If a child is affected by poliomyelitis, he must receive the vaccine
to prevent further infection from the other poliovirus types.
b-Passive immunization: Gamma- globulin.
Complication:
-Emotional disturbance. -Gastric dilatation. -Hypertension.

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 Encephalitis

Encephalitis is a term used to describe inflammation of the membranes

that surround the brain and spinal cord. Associated inflammation of the
meninges called meningo-encephalitis; while associated inflammation of
the spinal cord is called encephalo-myelitis.

This condition causes problems with the brain and spinal cord function.
The inflammation causes the brain to swell, which leads to changes in the
child's neurological condition, including mental confusion and seizures.

Causes encephalitis

The cause of encephalitis varies depending on the season, the area of the
country and the exposure of the child.

Viruses are the leading cause of encephalitis. viruses, including measles,

mumps, rubella and chickenpox, other viruses can cause encephalitis.
These include herpes simplex virus, West Nile virus (carried by
mosquitoes) and rabies (carried by a number of different animals).

Encephalitis can also occur following a bacterial infection, such as

tuberculosis and syphilis, and by parasites, such as toxoplasmosis (carried
by cats.

Clinical picture of encephalitis

Encephalitis often is preceded by a viral illness such as an upper

respiratory infection, or a gastrointestinal problem such as diarrhea,
nausea, or vomiting. The following are the most common symptoms of
encephalitis. However, each child may experience symptoms differently.
Symptoms may include:

-Fever

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-Headache (or bulging of the fontanelles, the soft spots on a baby's head)

-Sensitivity to light -Neck stiffness

-Sleepiness or lethargy -Increased irritability

-Seizures -Skin rashes

-Difficulty talking and speech changes

-Changes in alertness, confusion, or hallucinations

-Loss of energy -Loss of appetite

-Unsteady gait - Nausea and vomiting

Diagnosis encephalitis

Diagnostic tests that may be performed to confirm the diagnosis of

encephalitis may include the following:

-X-ray .

-Magnetic resonance imaging (MRI) .

-Computed tomography scan (also called a CT or CAT scan) .

-Blood tests

-Urine and stool tests

-Sputum culture .

-Electroencephalogram (EEG) .

-Lumbar puncture (spinal tap) .

Complications: -
-Death may occur during the acute stage.

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-Spastic cerebral palsy. -Epilepsy. -Mental
retardation.
-Auditory disturbances. -Personality changes

Treatment for encephalitis:

The goal of treatment is to reduce the swelling in the head and to prevent
other related complications. Medications to control the infection,
seizures, fever, or other conditions may be used.

The extent of the problem is dependent on the severity of the encephalitis

and the presence of other organ system problems that could affect the
child.

Treatments include the following:

1. Hospitalization :in order to confirm diagnosis, and exclude bacterial
meningitis
2. Control of convulsions: - ValiumIV .inj 0.1 – 0.2 mg/kg/4-6 hours.
Or EpanutinIV. Inj 15 mg/kg as a loading dose, then 5 mg/kg/day.
3. Measures to minimize cerebral edema and increased ICP : as
Mannitol, l Lasix.
4. As the child recovers, physical, occupational, or speech therapy may
be necessary to help the child regain muscle strength and/or speech
skills.
Nursing care
-Providing quite environment and maintain bed rest.
-Oral hygiene -Maintain adequate nutrition -Aspiration of
secretion
-The healthcare team educates the family after hospitalization on how to
best care for their child at home and outlines specific clinical problems
that require immediate medical attention by his/her physician. A child

234
with encephalitis requires frequent medical evaluations following
hospitalization.

Viral Hepatitis

Introduction

Viral hepatitis is a classification of infections that directly attack the liver

and can cause inflammation. Some types of viral hepatitis produce short
term problems (acute) of the liver, and people can recover from these
without long term issues. Other types of viral hepatitis produce chronic or
long-term issues. Five types of viral hepatitis are well described. These
are called Hepatitis A, B, C, D, and E.

Hepatitis A

Hepatitis A is a virus that infects the liver. The virus causes inflammation
of the liver (hepatitis).

Mode of transmission

Fecal oral route.

Through contaminated food and water directly or indirectly.

The virus is easily spread in areas that have poor sanitation or poor
personal hygiene.

Incubation period: 15- 30 days (from infection till jaundice appear).

235
Prevention of hepatitis A

Hand washing with soap and water after using the bathroom, changing a
diaper, or before preparing and eating food. Good personal hygiene and
proper sanitation help prevent the spread of the virus.

Prognosis

-Good, with full clinical recovery in more than 98% of cases.

-In about 1% of cases leads to acute fulminate hepatitis.

-No chronic hepatitis or cirrhosis

Hepatitis B

Hepatitis B is a virus that attacks the liver. Hepatitis B virus infection can
harm the liver in many ways. The virus can cause liver damage (cirrhosis)
and it can also cause liver cancer. However, medical treatment can help
prevent these complications.

Incubation period: From 50 - 150 days

Mode of transmission

The hepatitis B virus is spread by one of the following ways:

- The most common ways the virus is spread are through exposure to
blood or other bodily fluids of an infected person.

-From mother to fetus during/after pregnancy (perinatal).

-Contaminated syringe and needle stick.

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-The virus can also be spread by activities such as sharing toothbrushes
with an infected person.

Prevention of hepatitis B

-Active vaccination against Hb is now obligatory in Egypt. In Egypt, the

3 doses are given at 2, 4, 6 months

-If the pregnant are a carrier of the hepatitis B virus it is very important to
tell doctor before delivering your baby. If appropriate precautions are
taken it is likely that your newborn will not contract the infection
perinatally (after birth

-Avoid sharing toothbrushes or other article with an infected person.

Prognosis

The virus may lead to chronic active hepatitis, chronic persistent hepatitis
and finally liver cirrhosis.

Hepatitis C

Hepatitis C is an infectious blood-borne virus that attacks the liver.

Incubation period :From 15 - 180 days

Mode of transmission

The most frequent source of transmission is direct exposure to infected

blood. Risk factors for contracting the virus include: receiving blood
products from an infected person, sharing items such as syringes, or
needles that may have had blood on them. The virus can also be

237
transmitted during the perinatal period if an infant is born to a hepatitis C
virus infected mother.

Hepatitis C virus infection is not transmitted by kissing, hugging,

sneezing, coughing, food or water, or casual contact. Children infected
with hepatitis C virus should not be excluded from school, play, or any
other childhood activity based on their infection status.

Prevention of Hepatitis C virus:

Currently, there is no vaccine available to prevent the transmission of

hepatitis C virus from person to person. In order to protect your child
make sure your child does not have direct contact with infected blood.
This means your child should not share items such as needles or
toothbrushes since they might have had another person's blood on them.

Prognosis

Chronic hepatitis C infection can lead to liver failure requiring liver

transplantation.

Hepatitis D

Hepatitis D virus, also known as Delta, is a virus that attacks the liver.
Hepatitis D virus infection can only occur in people who have hepatitis B
virus infection. About 5% of people with hepatitis B virus infection will
also have infection with the hepatitis D virus.

Incubation period: From 2 - 8 weeks

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Mode of transmission: As hepatitis B virus

Prevention of hepatitis D: As hepatitis B virus

Hepatitis E

Hepatitis E, also known as Enteric non-A, non-B is a virus that attacks

the liver and causes inflammation of the liver.

Incubation period:From 45 days (15-60 days)

Mode of transmission:As virus A

Prevention of hepatitis E:As virus A

Clinical manifestation of viral hepatitis

It varies from asymptomatic to severe clinical manifestation.
It is classified into 3 stages:
1- Preicteric stage:
It include onset of fever, malaise, fatigue and digestive symptoms as:
nausea, vomiting, anorexia.
2- Icteric stage:
It is represented by enlarged tender liver and right upper abdominal pain.-
-Then jaundice appears dark urine and light or clay stools. Artheralgia
and arthritis strongly suggested hepatitis B virus.
-Spleen and lymph node are slightly enlarged.
3- Recovery stage:
All symptoms return within normal for few months.
Laboratory Investigation of viral hepatitis
Urine : increase urobilinogen initially, then disappears after appearance of
jaundice

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WBCs count : leucopenia and lymphocytosis in the first 2 weeks of
illness.
Serum liver enzymes: SGOT &SGPT are elevated
Serum bilirubin : both direct and indirect bilirubin are elevated
Hepatitis marker are elevated
Treatment of viral hepatitis
*in uncomplicated cases: the treatment is supportive.
-bed rest.
-Low fat, high carbohydrate diet
-If severe emesis:-
IV fluids to avoid dehydration.
-Steroids are not indicated, except in severe cases, for 5 days then the
dose rapidly reduced.
-Recently, interferon is used for treatment of hepatitis B
*If acute fulminate hepatitis:
Manage the patient acute problems. While waiting for restoration of liver
function.-
-Bleeding: vit-K, fresh plasma or whole blood may be needed.
Fluid retention:-
- Paracentesis if ascities leads to respiratory distress.
-IV albulmin.
-Maintenance of adequate nutrition & glucose 10 % IV infusion to
prevent hypoglycemia.
Nursing care
1-Maintain bed rest.
2-Diet: Diet should contain high K, Ca, fruit drinks and carbohydrates
were acceptable, moderate amount of protein.
Low fat diet.-
3-Prevent spread of infection:
All foods articles should be personal in hepatitis Avirus.-
-Preventive measures should be followed in hepatitis B & C

241
Respiratory Disorders

Prepered by

Dr. AsmaaAwad

241
Respiratory disorders are the most common causes of illness and
hospitalization in children. The child’s age and living conditions
and the season of the year can influence the etiology of
respiratory disorders as well as the course of illness

Croup
Children between 3 months and 3 years of age are the most
frequently affected with croup, though croup may affect any
child.
Definition:
Croup is a viral infection that causes the upper part of the
larynx to swell and is usually caused by one of the cold viruses.

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Croup is referred to as laryngotracheobronchitis because
inflamation and edema of the larynx, trachea, and bronchi occur
as a result of viral infection.
Pathophysiology:
The inflammation and edema obstruct the airway, resulting
in symptoms. Mucus production also occurs, further
contributing to obstruction of the airway. Narrowing of the
subglottic area of the trachea, edema of the larynx causes
hoarseness.
- Inflammation in the larynx and trachea causes the
characteristic barking cough of croup.
- Symptoms occur most often at night, with resolution of
symptoms in the morning.
- Croup is usually self-limited, lasting only about 3 to 5
days.
Causes
- Children younger than five years of age are more likely to
become infected with croup.
- Children may develop croup after breathing respiratory
droplets infected with the virus.
- Croup is usually caused by parainfluenza viruses (viruses
causing upper respiratory infections (colds) or lower
respiratory infections (pneumonia).
- Virus particles may survive on toys or other surfaces.

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Sign and symptom
- Croup features a cough that sounds like a seal barking.
Most children have a mild cold for several days before the
barking cough occurs.
- As the cough becomes more frequent, labored breathing
or stridor (a harsh, crowing noise made when breathing in)
may occur.
- Croup is usually worse at night and lasts for five or six
nights. In severe cases, the upper airway may become
swollen to the point that it is blocked off (airway
obstruction).
- Fever and cold symptoms.
Diagnosis
look for signs such as a barking cough and stridor (squeaking
sound on inhaling). Additionally, the child will be checked for
fever and cold symptoms and the doctor will determine whether
there is a prior history of croup or airway problems.
Complications of croup are rare but may include
- Respiratory distress.
- Hypoxia.
- Bacterial superinfection.
- Croup is usually managed on an outpatient basis, with only
1% to 2% of cases requiring hospitalization.

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Treatment:
Corticosteroids (usually a single dose) are used tohelping to
decrease edema and inflammation.
Health education:
1. Expose child to humidified air.
2. The child must be observed closely.
3. Keep the child quiet and discourage crying.
4. Encourage rest and fluid intake.
5. If stridor occurs, take the child into a steamy bathroom
for 10 minutes.
6. Watch the child closely, call the physician if:
 The child breath faster, has retractions, or has any
other difficult breathing.
 The nostrils flare or the lips or nails have bluish
tint.
 The cough or stridor does not improve with
exposure to moist air.
 Restlessness increases or the child is confused.
 The child begins to drool or cannot swallow.
Prevention and screening for upper respiratory infection:
 Frequent hand washing remains the most important
preventive measure for most URIs.
 Simple measures, such as covering the mouth and nose
while sneezing.
 Vitamin C may reduce the incidence of colds by 50%
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  Multivitamin and mineral supplements.
 Influenza vaccine is recommended.

PNEUMONIA
Definition:
Pneumonia is an inflammation of the lung parenchyma. It
can be caused by a virus, bacteria, mycoplasma, or fungus. It
may also result from aspiration of foreign material into the
lower respiratory tract (aspiration pneumonia).
Pneumonia Common in child age 6 months to 3 years and
occurs more often in winter and early spring. It is common in
children but is seen most frequently in infants and young
toddlers.
Pathophysiology

Pneumonia occurs as a result of the spread of infectious

organisms to the lower respiratory tract from either the upper
respiratory tract or the bloodstream.

In bacterial pneumonia, mucus stasis occurs as a result of

vascular engorgement. Cellular debris (erythrocytes,
neutrophils, and fibrin) accumulates in the alveolar space.

Signs and Symptoms:

- High fever

- Dry cough - in early stages (Non-productive cough )

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- Productive cough - in later stages

- Wet cough that produces white or yellow phlegm

- Cough with thick yellow-green mucus

- Cough with rust-colored sputum

- Retraction (when muscles under the rib cage or between

ribs draw inward with each breath).

- Blood in sputum

- Increased respiratory rate

- Chest pain on breathing cough

- Vomiting

- Abdominal pain

- Decreased activity

- Loss of appetite (in older kids) or poor feeding (in infants)

- Cyanosis.

- Tachycardia

- Shivering

- Sweating

- Rhinitis

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Risk factors:

- Prematurity

- Malnutrition

- Passive smoke exposure

- Low socioeconomic status

- Daycare attendance

- Underlying cardiopulmonary, immune, or nervous system

disease

Causes:

- Bacterial: pneemococci, streptococci and stapcoccity.

- Viral: adeno virus.

- Aspirated pneumonia: due to aspiration for any fluid.

- Hypostatic pneumonia: due to weakness in respiratory

muscles.

- Other cause: inhalation in chemical substance.

Classification of pneumonia

1) Lobar pneumonia: diffused inflammation effecting on

one or more lobe of the lung.

2) Broncho-pneumonia: patchy inflammation effecting in

bronchi and surrounding area of alveoli.
248
 3) Interstitial pneumonia: inflammation is limited to the
interstitial tissue.

Diagnosis:

Health History

Physical Examination

Laboratory and Diagnostic Tests

laboratory and diagnostic studies include:

• Pulse oximetry: oxygen saturation

• Chest x-ray

• Sputum culture

• White blood cell count

• CT scan.

Treatment

- Antipyretics.

- Adequate hydration.

- Close observation.

- Give oxygen.

- Intravenous hydration.

- Antibiotics.

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 Complication of Pneumonia

1) Pulmonary complication:

- Plural effusion, which accumulation of fluid in the chest

respiratory failure.

- Lung abscess.

2) Extra pulmonary complication:

- Toxic myocardities and acute congestive heart failure.

- Septicemia and may be septic shock.

- Neck rigidity.

Nursing management

- Take vital signs.

- Check for respiratory rate.

- Observe color for skin off child if he has cyanosis putting.

- Minting air way open and clear.
- Provide for the child warm fluid.
- Maintain intake and output fluid and making intake and
output chart.
- Making suction if child need to maintain air way clean.
- Weight the child daily.
- Cold compresses if the child hyperthermia.

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 ASTHMA
Definition:
Asthma is temporary narrowing of the bronchi by
bronchospasm, caused by hypersensitivity and inflammation of
the lower airways that leads to bronchial edema and mucus
hypersecretion, manifested as dyspnea, wheezing and excessive
cough.

Incidence:
Disease affects 5% to 10% of all children. The peak
incidence is found in 5 to 10 years of age. Boys are more
sufferer than girls.
Pathophysiology

The extrinsic triggers factor leading to obstruction due to

edema of the respiratory mucosa causes bronchilar narrowing,
increased production of thick mucus secretion accumulation,
and bronchial and bronchilar smooth muscle spasm. This leads
to air trapping, characteristic wheezing, and respiratory distress.
Predisposing Factors of Asthma:
- Ingestion of certain foods such as chocolate, milk, eggs,
nuts, and some fish.
- Food additives.
- Inhalation of irritants such as cigarette smoke, wool, dust,
animal hair, odors, sprays.
- Change in climate as exposure to cold weather.

251
 - Infections, such as bronchitis and upper respiratory
infection.
- Emotional stress or anxiety tension, fear and conflict.
- Excessive fatigue, exhaustion and exercise.
- Some types of medication.

- Heredity, with a family history of asthma.

- Air pollution.

Clinical Manifestation

- Tightness of chest

- A dry, hacking cough.

- Wheezing.

- Difficulty breathing.

- Tachycardia.

- Restlessness, itching, polyuria and mental excitement.

- Difficult of sleep.

- Cyanosis.

- Chest retractions.

- Abdominal pain and vomiting may found in intense cough.

Diagnosis

 History:

 Physical examination:

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  Diagnostic tests:

a) Radiographic examinations.

- Pulmonary function tests (PFTs) that indicate the amount

of obstruction in the bronchial airways.

- A spirometer test to assess the severity of airway

obstruction.

- Attach a pulse oximeter to moniter oxygen saturation.

b) Laboratory tests.

- ABG.CBC.

- Allergy test to identify allergens.

- Sputum culture.

Management of Asthma

The goals of asthma treatment include:

1) Preventing of acute attacks and maximum control of

symptoms day or night.

2) Maintaining near normal lung function.

3) Maintenance of normal level of growth and development.

4) Preventing recurring hospitalizations.

5) No activity limitation, no school missed, and no missed

work by parent.

6) Avoidance of allergens.

253
If the child has an asthma attack at home the caregiver
should take the following steps.

1) Use local treatment immediately.

2) Place the child sit down (not lie down) and relax.

3) Wait five to 10 minutes until symptoms go away.

4) If symptoms don't go away, should call GP or an

ambulance, but continue use local treatment every few
minutes until help arrives.

5) If go to hospital, should take asthma treatments with the

child.

Therapeutic Treatment

- Bronchodilators.

- Antiasthmatic as corticosteroids preparation.

- Oxygen therapy.

- Nebulizer.

- IV fluid.

- Antibiotic.
Complications:
- Delay in growth and development.
- Pulmonary dysfunction.
- Difficult in school achievement.
- Pulmonary rupture.- Death.

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 Parents Reactions toward the Imperfect Child

Out lines:

Definition of imperfect child.

Parent’s reactions toward the imperfect child.

Nursing roles toward parents have imperfect child.

 Definition of imperfect child

Child has any deformity that may be mentally, physically
or socially as chronic illness, disability, and handicap.

 Parent’s reactions toward the imperfect child

I- Shock and disbelief:

It is the initial response of parent to learn the deformity.
- Shock and disbelief are usually short-lived.
- Shock increase anxiety level and makes it difficult for
parents to comprehend information about the case and
cause distortion of information.
II-Denial:
It is normal defense mechanism.
- It is effective in helping the parent to cope with anxiety
and pain by making condition less fear some while
allowing parents to gather the resources.

255
 - (Doctor-shop) in hope to finding solution, but interfere
with the treatment.
- It is usually decreases as the reality of the disease becomes
increasingly difficult to ignore.
III- Awareness of handicap:
1- Guilty feelings: Parents feel guilty and responsible for the
child’s condition especially if the condition is genetic, and also
due to lack of their power to prevent the disease.
2- Anger: It may be directed toward the nursing or medical staff
or even God or themselves. It is expressed openly as in ―why
God would let this happen to child‖.
3- Depression: Are commonly seen especially when parents can
not prevent the disease from progressing.
4-Overprotection:
- Parents give excessive attention to the child and often feel
they are the only ones who can adequately provide care.
- Child become dependent on his parents, develops mentally
delayed, loss of self-esteem and self-control and immature
behavior.
5- Sadness: feeling of sadness expressed by crying, inability to
sleep or somatic symptoms as headache & abdominal pain
IV- Restitution or recovery phase:
Parents tend to accept the child socially and emotionally.

256
  Nursing roles toward parents have imperfect child.
I- Helping parents to gain awareness of child’s defect
through:
- Helping parents see problem by drawing attention to
certain failure to walk or talk.
- Learning cannot take place until awareness of problem
exists.
II- Helping parents understand child’s potential ability and
assist them in setting realistic goals through:
- Teach parents how to work with their handicapped child in
simple childhood tasks as walking, talking, toileting,
feeding and dressing.
- Teach child how to stimulate child’s learning of new
skills.
III- Encourage parents to treat child as normally as possible.
Avoid overprotection and excessive attention given to this
child.
IV- Provide family with an outlet for own emotional tensions
and needs:
- Parent groups who have children with similar problem.
- Be a listener not a preacher.

257
Parasitic Infection

Prepared by
Dr.

AsmaaAwad
258
Objectives of this lecture
By the end of this lecture the student can
1- Describe the parts and functions of GIT organs
2- List Common Intestinal Parasites.
3- Identify main causes.
4- Enumerate signs and symptoms of parasitic infection
5- Explain how to prevent it
6- Identify its treatment
7- Understand its complications.

259
Intestinal Parasites

The Digestive System

Introduction
Infection by intestinal parasitic worms is widespread throughout the
world, affecting hundreds of millions of people. Children are particularly
susceptible have the largest number of worms. Three of the most
common kinds of worms are roundworm (Ascaris ), whipworm (Trichuris
trichiura) and hookworm (Ancylostoma). These worms live in the
intestines where they mature into adult worms. It is possible to be
infected with more than one kind of worm.In children, worms absorb up
to 30% of nutrients taken in from their food.

261
Common Intestinal Parasites

 Ascaris lumbricoides (roundworm)

 Trichuris trichiura (whipworm)
 Necatoramericanus (hookworm).
 Tapeworm
 pinworm

Main Causes
 Ingestion of undercooked foods

 Drinking infected water

 Infected water especially in countries where there isn’t a great

clean water system

 Also, ingestion of fruits and vegetables washed by parasite-infected

water

 Skin absorption through larvae infected soil, or in some cases, soil

with feces.

 When a toilet is not available in outdoors ears. The rain will come
and spread parasits over land that people walk.

General Symptoms

 Passing worms a mucous  Abdominal cramps and gas

and stools
 Diarrhea
 Immune suppression
 Nausea and vomiting
 Vaginal irritation
 Weight loss
 Joint pain
 Feeling tired

261
  Nighttime restlessness

 Loss of appetite

 Distended abdomen

 Coughing

 Fever

 Blisters on the lower lip

inside the mouth.

262
 Roundworm

 The larva mature in the lungs.

 The adult worms produce eggs which are shed in the feces.

 Most infections produce no symptoms.

They penetrate the intestinal wall and travel through the blood and lymphatic
system to the lungs.

They then ascend the bronchial tree and are swallowed. Once in the small
intestine, they mature into adult worms

Heavy infection can lead to nutritional deficiency or intestinal obstruction.

263
264
 Whipworm‫السوطية‬

 Shaped like a whip, the thin end is embedded in the mucosa while the thin end
extends into the bowel lumen.

 Eggs are shed into the stool.

 Inflammation of the colon, dysentery and rectal prolapsed may occur in those
with heavy infection.

 Dysentery is inflammation of intestines that leads to the passing of mucus and

blood in one’s stool; damages the body’s immune cells and leads to muscle
spasms of the intestinal muscles

Hookworm

 human nematode infection

 The worms are about 1/2 inch long.

 Produces anemia

 treatment consists of iron replacement

265
  Adults, especially agricultural workers, are at equal or higher risk of exposure
than children

 For hookworm, people become infected when the larvae burrow through the
skin of bare feet

 The larvae get into the skin. The larvae move to the lungs via the bloodstream
and enter the airways.

 After the larvae are swallowed, they infect the small intestine. They develop
into adult worms and live there for 1 or more years. Adult worms and larvae are
passed into the feces.

 Hookworm causes bleeding in the intestines and loss of blood, leading to iron
deficiency.

Tapeworm

 Caused by eating raw or undercooked meat of animals infected with tapeworms

 Grow in the intestines

 Eggs also be spread by infected individuals with poor hygiene

 No major symptoms, but abdominal pain may occur.

 Can be diagnosed by passing segments through stool

 Can grow to be up to 12 feet long and can live for years.

266
  Tapeworms have many segments and each segment can produce eggs which
pass through stool.

The Tapeworm Cycle

Pinworm

267
  Very small

 Most common in school-age children

 Spread by direct contact

The cycle

 They can also be spread by touching bedding, food, or other items contaminated
with the eggs.

 Typically, children are infected by unknowingly touching pinworm eggs and

putting their fingers in their mouths.

 The eggs are swallowed, and eventually hatch in the small intestine.

 The worms mature in the colon.

 Female worms then move to the child's anal area, especially at night, and
deposit more eggs.

 This may cause intense itching. The area may even become infected. When the
child scratches the itching anal area, the eggs can get under the child's
fingernails.

 These eggs can be transferred to other children, family members, and items in
the house.

 You can see them normally during the night and remove them.

Preventing Re-infection:

 Be sure that all meat, chicken and fish are cooked thoroughly.

 Don't use a microwave to cook meat, chicken or fish. Microwaves often don't
cook foods completely.

 Wash all fruits and vegetables in clean water before eating

268
  Always wash hands and kitchen counters with hot soapy water after cutting or
handling raw meat, chicken or fish.

 Always wear shoes or slippers (to prevent hookworm infection)

 Do not use water from septic tanks or other potentially contaminated sources.

 Teach children proper hygiene i.e. washing hands after going to the toilet,
playing outside and before preparing or eating food.

 If the child has parasites, he should carefully washing hands after having bowel
movements.

 Wear gloves when changing the cat box.

 Avoid swallowing river, stream or lake water when swimming in them. .

 Eat high-fiber foods and avoid sugar and other refined carbohydrates.

 Keep the body slightly acidic.

Treatment

The drugs most physicians use against parasitic infection work on the differential
toxicity which means that the drug is hopefully more toxic to the parasite than to
case. Side-effects include nausea, vomiting, abdominal pain, rashes and headaches.

Complications

 Heavy infections with roundworm can cause bowel obstruction.

 The long-term presence of parasites may contribute to the development of food

allergies.

 Intestinal worms – especially hookworm – can contribute to anemia by

causing intestinal bleeding and thus loss of blood.

 Chronic infections can lead to long-term retardation of mental and physical

development.

 In very severe infections it may cause death.

269
Gastrointestinal Tract

271
 Gastroenteritis
Introduction:
Gastroenteritis is a common worldwide problem. Five millions of children
under the age of 5 years die every year with the complications of severe
gastroenteritis. Most of these deaths occur in underdeveloped countries where
nutritional deficiencies and environmental pollutions are common.

Gastroenteritis is defined as inflammation of gastro intestinal tract (GIT) manifesting

clinically by diarrhea, vomiting and fever.
Gastroenteritis is the most killer of infant in Egypt.

Causes of Gastroenteritis:
1. Non infectious causes
Dietetic causes
Over feeding
Rapid feeding
Excessive carbohydrates
Swallowing of air
Allergic food
2. Environmental factors….
Unhygienic environment.
3. Host factor
Young age,
Immunity deficiency
Bad nutritional status
Immune deficiency disorders
Chronic illness
4. Infectious causes
a. Parenteral infection……outside GIT
271
Bronchopneumonia, Pneumonia, Bronchitis, common cold, influenza
Otitis media
Tonsillitis
Pharyngitis
Sore throat
Urinary tract infection
5. Enteral infection…. inside GIT
— Bacteria….salmonella, Shigella, E. coli, Staphylococcus, cholera.
— Viral…. Rota virus, enterovirus, adenovirus
— Fungal….Monilia albicans
— Parasitic…..Entameba, giardia lamblia, bilharzial
Clinical manifestation:
— Diarrhea
— Vomiting
— Fever
— Malaise/ irritability
— Anorexia
— Abdominal colicky pain
Diarrhea for 6-20 time /day
— Changed stool
Offensive odor, pus, mucous, blood, color
— Abdominal distension
Diagnosis
Diagnosis of gastroenteritis is clinical and depends on the presence of acute
diarrhea with or without fever and vomiting. Accurate diagnosis should include
assessment of severity (mild, moderate, severe), possible causative organism
(bacterial, viral, parasitic), and the associated complications.
1. Bacterial gastroenteritis: The possibility of bacterial enteritis is considerable
when the fever is above 38.5°C and the diarrhea is severe or bloody. The

272
 main 5 causative, organisms are shigella, salmonella, E.coli, campylobacter
and yersinia enterocolitica. The stool character is a useful guide in
suggesting the causative organism. Accurate differential can be only made
by stool culture.
2. Viral gastroenteritis: Fever is usually below 38°C and the diarrhea is usually
watery and not severe. Rotavirus is by far the most common causative
agent.
3. Parasitic enteritis: Clinical manifestations depend on the causative agent.
With Giardia lamblia infection, the diarrhea is usually watery, foul-
smelling, not severe and not associated with fever. With amoebiasis,
diarrhea is commonly bloody but fever is absent.
Diagnosis of complications:
Several complications are common with severe gastroenteritis and are
responsible for the high morbidity and mortality. These complications are most
common in infants with severe bacterial gastroenteritis.
Metabolic complications:
Dehydration, metabolic acidosis, electrolyte disorders and acute renal failure.
Cardiovascular complications:
Shock (circulatory failure)
Neurologic complications:
Convulsions
Coma: due to severe dehydration ,sever acidosis, electrolyte disturbance.
Hematologic complications:
Bleeding
Digestive complications:
Persistent diarrhea: Persistent infection, malabsorption, malnutrition
Management
Mild and moderate cases of gastroenteritis can be safely managed at home.

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Prevention of dehydration, dietetic management and symptomatic treatment (fever,
vomiting) are the main lines of therapy. Follow-up and re-evaluation within few days
is important to identify deteriorating cases requiring hospital management. Severe
cases should be hospitalized, closely monitored and urgent managed.
1. I.V. fluid therapy: It is indicated for treatment of shock, correction of
dehydration, reversal of prerenal failure and treatment of acid-base and
electrolyte disorders.
2. Antibiotic therapy: is indicated in patients with high persistent fever
especially when associated with early septic shock or laboratory
manifestations suggesting severe bacterial infection. Ampicillin (100
mg/kg/day), or cefotaxime (100 mg/kg/day), I.V. in 2-3 divided doses.
Therapy is continued for at least 5 days.
3. Treatment of complications: renal failure, convolutions and bleeding are
common complications in severe cases.

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 Dehydration

Definition: Mean zloss or deprivation of water but it is employed loosely to

include loss of water and various ions from the body without specifying the source of
either the water or accompanying. Ions, most cases present with features indicating
deficiencies both of water and sodium.

Causes of dehydration:-
-Excessive fluid loss
a- Excessive sweating.
 High fever.
 Not climate.
 Cystic fibrosis
b-Vomiting.
 Pyloric stenosis.
 Viral infections.
 Gastroenteritis.
c-Fluid loss.
 Burns.
 Post surgery.
d-Polyuria.
 Diabetes mellitus, especially diabetic ketoacidosis.
e-Acute diarrhea.
 Viral, bacterial gastroenteritis.
 Antibiotic – induced.
 Food poisoning.
 Any acute infection.
f-Inadequate intake.
 Inability to drink.
- Herpes stomatitis.
- Acute tonsillitis.
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Health education to parents regarding management and prevention about
diarrhea and dehydration:
Educate the parents and child to wash their hands and exposed arms with soap
and warm water before eating and after toilet or diaper changes. Finger nails should be
kept clean and trimmed.
- Educate the parents or caregiver on how to identify signs of dehydration.
- Describe and demonstrate to parents the amount of oral rehydration therapy to
begiven using alocal measure.
- Instruct the parents to avoid use of antidiarrheal drugs and antiemetics.
- Instruct the patient to avoid exposure to the causative agent.
- Stress the need to follow enteric precautions.
- Emphasize strict hand washing before and after food preparation feeding ,
handling of persons and animals, stool elimination, diapering and laundering.
- Encourage laundering of contaminated linens , clothes and other articles.
- Encourage proper storage, preparation and hand ling of food.
- Instruct he parent how to collect stool specimens.
- Teach about the cause of diarrhea and any medications, if prescribed.
- Advise the parents that for E.coli, shigella, lamblia infections the child should
n’t center school or the day-care center until diarrhea has stopped and stool
cultures are negative.
- Follow up: make telephone call or schedule are turn visit immediately if the
child refuses to drink, has a high or prolonged fever, has adecrease in urinary
out put, is unable to retain fluids, has blood in stool, lethargy, irritability,
weight loss, and chronic diarrhea.
Consultations and referrals: consult with physician for
 Patient under 3 months of age.
 Diarrhea persisting over 72 hours.
 Moderate to sever dehydration.
 Report to local health department.

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Congenital anomalies

Prepared

Dr/ Eman Hassan

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Congenital Anomalies
Definition:
An anomaly is a structural defect present at birth. Some defects may be
compatible with life but need treatment that could be delayed. Others are in
compatible with life and must be repaired immediately.
Causes of Fetal malformations:
Several factors are known to produce malformations of the developing fetus.
These are environmental factors including:
1-Drugs
2- Radiation
3- Viruses like rubella virus
4- Genetic traits
Common anomalies, of the different systems are as follows:

Gastrointestinal system:

Anomalies of the Intestine:

Hirshsprung's disease: (congenital A ganglionic Mega colon).
-There is congenital absence of parasympathetic ganglion nerve cells of a part of
intestine usually in the distal end of the descending colon/the affected portion has
no peristalsis.
-It is common in males & females. It then hypertrophies with accumulation of
feace.

Symptoms and signs:

 -Failures to pass meconium within 24-48 hours after birth.

 -vomiting.
 -Abdominal distention.
 -Food refusal.

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 Diagnosis:

 In neonate:usually based on clinical signs of intestinal obstruction and failure to

pass meconium.
 On examination, the rectum is empty of faces.
 Rectal biopsy
 Anorectal manometery.
Treatment:
 -Surgical removal of Aganglonic portions of the bowel in order to permit normal
bowel motility and establish continue by improved functioning of the internal anal
sphincter.
 Surgery consists of first stage and second stage.
Acquired Intestinal Defect: Intussusceptions: It is an acquired type of intestinal
obstruction. It is the invagination of a portion of the bowel in to the portion
immediately distal to it; thus the blood supply is out off and if the condition
continues, the bowel will become gangrenous. Death may result if the condition is not
recognized and corrected sometimes a simple reduction occurs.
Incidence:
 -Intussusceptions is one of the most frequent causes of intestinal
obstruction in children between the ages of 3-5 years.
 -The male to female incidence is 2:1.
 -The peak incidence is in summer due to increased gastroenteritis.
 -This may explain the frequent occuranous of intussusceptions at the age
of 3-12 months (age of weaning).
Symptoms and signs:
Symptoms:
 -The infant awakens from sleep by severe abdominal colic, screams and draws
his knees up into the abdomen. These attacks alternate with intervals of
apparent well-being during which the infant asks for feeding.
 -With each attack of pain there is pallor, apathy and lethargy.
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  -Vomiting follows the attacks of colic in 85% of cases.
 The infant passes mucous and blood per rectum (red currant jelly stool).
Signs:
 -Emptiness in the right iliac fossa (Signe de Dance).
 -A sausage shaped mass may be felt.
 -Distention is usually absent in early cases. If it occurs it denotes possible
perforation or gangrene.
 -Digital rectal examination revels bloody mucous in 60% of cases.

Investigations of infantile ilocacal intussusceptions:

 -Blood picture shows anemia.

 -Gastro Raphine enema. (claw sign).
 -Ultrasound examination.
Treatment of infantile ilocacal intussusceptions:
 -Resuscitation of the I.V. infusion of dextrose and saline.
 -Antibiotics are prescribed.
 -A nasogastric tube is inserted.
 -In early cases a trial of hydrostsstic reduction is performed:
*The pressure should not exceed120cm of sterile water, air, gastrographine and
normal saline.
Contraindication hydrostsstic reduction:
 -Doubtful diagnosis.
 -Late cases.
 -Presence of abdominal distension or rigidity.
Surgery:
-Is needed when hydrostsstic reduction fails.
-A lapartomy.
Prognosis of infantile ilocacal intussusceptions:
-Mortality high in dangerous cases.

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- Intussusceptions: may occur in 2% of cases.

Congenital Heart Diseases

1- Congenital heart disease with no shunt
 Coarcutation of aorta
 Aortic stenosis
 Pulmonary stenosis
2- Congenital heart disease with shunt and cyanosis
 Fallout's tetralogy
 Transposition of great vessels.
3- Congenital heart disease with shunt but no cyanosis
 Patent ducts arteriosus P.D.A
 Interatrial septal defect A.S.D
 Interventricular septal defect V.S.D

Congenital Heart Disease With No Shunt

Coarcutation of aorta
A narrowed segment along the aorta it associated with duct arteriosus, characterized
by cardiac murmur, hypertension due to left heart failure, weak or absent femoral
pulse and left ventricles hypertrophy with or without failure Investigation:- E.C.G, x-
ray, aortogram
Treatment:- surgical correction in late childhood

Congenital heart diseases with shunt but no cyanosis

Atrial septal defect (A.S.D) is small defect cause minimal change in cardiac function,
diagnosed accidentally, large defect are associated with failure to thrive, repeated
chest infection and exertional dyspnea, murmur.
Investigation: x-ray, E.C.G, Echo (electrocardiograph) and catheterization.
Treatment: surgery

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Ventricular septal defect (V.S.D) is small defect is asymptomatic, and is diagnosed
accidentally during examination, charactrized by harsh murmur, loud and always
associated with a thrill large defect characterized by recurrent chest infection, failure
to thrive and exertionaldyspnea, may be cyanosis on crying or heart failure ,
pulmonary hypertension, develops reversal of the shunt many occurs leading to
persistent cyanosis.
Investigation:Echocaidiogram, E.C.G and x-ray
Treatment: in small defects antibiotics in septic procedures and in large defect
surgical repair
Patent dictus arteriosus
Is persistence of a fetal duct between the pulmonary artery and the aorta.
Clinical picturedepends on the size of the duct, small ducts may be asymptomatic and
discovered accidentally on routine examination of the heart, wide ducts cause failure
to thrive, dyspnea, sometimes heart failure, pulmonary hypertension, murmur heard on
the base of the heart.
Investigation E.C.G - x-ray – catheterization.
Treatmentligation as early as possible specially with heart failure.

General Aspects of pre and post-operative pediatric care:

A. Transportation of the newborn:-

1- Safe means of transportation with a heated portable incubator and available oxygen
supply is needed so as to maintain the infant's body temperature and 02 level in the
blood
2- Equipment for suctioning to remove secretions is needed (as in esophageal
atresia).
3- A Nurse should participate in the transfer of the baby to observe him during that
time and give appropriate care proper positioning of infant)
4- All pertinent infant information should accompany the infant as he goes from one
health agency to another.

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B. Pre-operative care:

1- Psychological preparation of the child (according to is age) this is aimed at

prevention fears common to children like fear of separations, fear of death. The
nurse should explain to the child and his families what is going to occur.
2- Except in emergency situations, children should preferably be free of respiratory
complication and sings of malnutrition.
3- Most children must have nothing by mouth before surgery but the length of the time
the child remains NPO will depend on age (for newborns & infants 3-4 hours is
usually enough ).
4- The incision over or the part involved in surgery must be washed and inspected .
Shaving may be needed .
5- The mouth should be checked for loose or missing teeth should be charted in the
child's record .
6- Remove barretts and pins from the child's hair.
7- Clothing should be warm and loose. The child should be dressed in a hospital gown
and under pants only .
8- Check the child's identification band to see that is legible and secure. If not it needs
to be replaced prior to surgery.
9- Pre-medication : sedatives and analgesics are usually given two hours before
surgery except in emergency situations ) .
10- The nurse should chart whether the child has passed urine and had a bowel
movement . Enemas are never done routinely but may be ordered in some
conditions .
11- Prior to taking the child to surgery, specially in newborns and infants, nostrils
should be carefully cleansed (hard crusts may be softened with a solution of
sodium bicarbonate, normal saline, or even warm water) This is necessary because
crusts may be obstructing the air way)
12- The child may need to take his favourite toy with him to surgery. Ideally, he
should be allowed to keep the toy with him until he is under the anesthetic.

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13- Parents should be allowed to accompany their children to the operating site if they
so desire.
14- Parents should be told where to wait during surgery, whether the child will go to
recovery room after surgery or directly to his unit.

C- Post- Operative care:

1- After return from the operating room, the child's general condition must be closely
observed (a) vital signs, especially temperature
(a) Airway must be kept patent
(b) newborn babies must be kept in warm cot or incubator .
2- Until the child is responsive and alert, he should be kept on his side (for secretion
and vomits to get out from mouth)
3- Observe conditions and placement of dressing . Check and mark any apparent
drainage from wound .
4- Intravenous fluids should be checked for correct rate of flow and for possible
infiltration .
5- The child should be carefully handled and should be protected from harming
himself by use of appropriate restraints .
6- Any urinary catheter should be connected to drainage bag and stabilized properly
to bed .
7-Observe patient's skin color and temperature, as well as any signs of shock:
8- Oral fluids may be started after the following criteria are observed:
(a) color of aspirate is clear
(b) peristaltic movements are heard
(c) flatus or gases are passed.
9- Oral fluids should be started while infusion still on. if well tolerated then infusion
is gradually discontinued. Routine postoperative diet is modified according to
child's age, but in general it changes from clear of liquid, full liquid, soft and then
regular diet.
10- Sedatives are used according to prescribed orders and child's need.
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11- For children who can walk, early progressive ambulation is the rule
( expect in few cases), this will help to restore gastrointestinal function and prevent
complications as pneumonia, the thrombosis, and pressure areas. If too young to
get out of bed, the nurse should turn the child frequently and give him good skin
care and help him to breath deeply at intervals.

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 Down syndrome

Autism

Attintion Deficit Hyperactivity Disorder

Prepared by

Dr. Eman Hassan

286
 Down syndrome
Definition:

Down syndrome is a genetic disorder caused when abnormal cell division results in an
extra full or partial copy of chromosome 21.

Down syndrome varies in severity among individuals, causing lifelong intellectual

disability and developmental delays. It's the most common genetic chromosomal
disorder and cause of learning disabilities in children. It also commonly causes other
medical abnormalities, including heart and gastrointestinal disorders.

Symptoms:

Each person with Down syndrome is an individual — intellectual and developmental

problems may be mild, moderate or severe. some of the more common features
include:

 Flattened face

 Small head

 Short neck

 Protruding tongue

 Upward slanting eye lids (palpebral fissures)

 Unusually shaped or small ears

 Poor muscle tone

 Broad, short hands with a single crease in the palm

 Relatively short fingers and small hands and feet

 Excessive flexibility

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  Tiny white spots on the colored part (iris) of the eye

 Short height

Infants with Down syndrome may be average size, but typically they grow slowly and
remain shorter than other children the same age.

Causes

Human cells normally contain 23 pairs of chromosomes. One chromosome in each

pair comes from your father, the other from your mother.

Down syndrome results when abnormal cell division involving chromosome 21

occurs. These cell division abnormalities result in an extra partial or full chromosome
21.

Risk factors

 Advancing maternal age.

 Being carriers of the genetic translocation for Down syndrome. Both men and women can
pass the genetic translocation for Down syndrome on to their children.

 Having had one child with Down syndrome. A genetic counselor can help parents assess the
risk of having a second child with Down syndrome.

Complications

People with Down syndrome can have a variety of complications, some of which
become more prominent as they get older. These complications can include:

 Heart defects. About half the children with Down syndrome are born with some
type of congenital heart defect.

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  Gastrointestinal (GI) defects. GI abnormalities occur in some children with
Down syndrome and may include abnormalities of the intestines, esophagus,
trachea and anus.

 Immune disorders. Because of abnormalities in their immune systems, children

with Down syndrome are at increased risk of developing autoimmune disorders.

 Sleep apnea. Because of soft tissue and skeletal changes that lead to the
obstruction of their airways, children and adults with Down syndrome are at
greater risk of obstructive sleep apnea.

 Obesity. People with Down syndrome have a greater tendency to be obese

compared with the general population.

 Spinal problems. Some people with Down syndrome may have a misalignment
of the top two vertebrae in the neck .

 Leukemia. Young children with Down syndrome have an increased risk of

leukemia.

 Dementia.

 Other problems. Down syndrome may also be associated with other health
conditions, including endocrine problems, dental problems, seizures, ear
infections, and hearing and vision problems.

Treatment

Early intervention for infants and children with Down syndrome can make a major
difference in improving their quality of life. Because each child with Down syndrome
is unique, treatment will depend on individual needs. Also, different stages of life may
require different services.

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Team care

Depending on child's particular needs, as

 Primary care pediatrician to coordinate and provide routine childhood care

 Pediatric cardiologist

 Pediatric gastroenterologist

 Pediatric endocrinologist

 Developmental pediatrician

 Pediatric neurologist

 Pediatric ear, nose and throat (ENT) specialist

 Pediatric eye doctor (ophthalmologist)

 Audiologist

 Speech pathologist

 Physical therapist

 Occupational therapist

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 Autism
Definition:

Autism, also called autism spectrum disorder (ASD), is a complicated condition that
includes problems with communication and behavior. It can involve a wide range of
symptoms and skills. ASD can be a minor problem or a disability that needs full-time
care in a special facility.

Signs and Symptoms

Common symptoms of autism include:

 A lack of eye contact

 A narrow range of interests or intense interest in certain topics
 Doing something over and over, like repeating words or phrases, rocking
back and forth, or flipping a lever
 High sensitivity to sounds, touches, smells, or sights that seem ordinary to
other people
 Not looking at or listening to other people
 Not looking at things when another person points at them
 Not wanting to be held or cuddled
 Problems understanding or using speech, gestures, facial expressions, or
tone of voice
 Talking in a sing-song, flat, or robotic voice
 Trouble adapting to changes in routine

Causes

 Exactly autism happens isn't clear. It could stem from problems in parts of your
brain that interpret sensory input and process language.

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  Autism is four times more common in boys than in girls. It can happen in people
of any race, ethnicity, or social background. Family income, lifestyle, or
educational level doesn’t affect a child’s risk of autism.
 Autism runs in families, so certain combinations of genes may increase a child’s
risk.
 A child with an older parent has a higher risk of autism.
 Pregnant women who are exposed to certain drugs or chemicals, like alcohol or
anti-seizure medications, are more likely to have autistic children. Other risk
factors include maternal metabolic conditions such as diabetes and obesity.
Research has also linked autism to untreated phenylketonuria (also called PKU,
a metabolic disorder caused by the absence of an enzyme) and rubella (German
measles).

Treatment

Psychotherapeutic: Applied behavior analysis, also known as ABA, is the most

widely accepted evidence-based autism therapy. ABA has been shown to help autistic
children develop needed skills and minimize undesired behaviors such as self-injury.

Occupational therapy, known as OT, is designed to help children acquire the skills
needed to perform the activities—or ―occupations‖—of daily life, including fine and
gross motor skills, sensory processing skills, self-help skills and more.

Many parents find using something called “Social Stories” to be helpful as well.
Social Stories are designed to be an engaging, interactive way of preparing children
for social situations. The stories, written from the child’s point of view, use narration,
photos and drawings to guide the child through an experience, preparing him for what
to expect.

Pharmacological: There are no drugs that target the core symptoms of autism,
but medications are often prescribed to help with problems that often occur alongside
the disorder, such as depression, anxiety, and hyperactivity.
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 Attention-deficit / hyperactivity disorder (ADHD)
Definition:

ADHD is one of the most common neurodevelopmental disorders of childhood. It is

usually first diagnosed in childhood and often lasts into
adulthood. Children with ADHD may have trouble paying attention, controlling
impulsive behaviors (may act without thinking about what the result will be), or be
overly active.

Symptoms

The primary features of ADHD include inattention and hyperactive-impulsive

behavior. ADHD symptoms start before age 12, and in some children, they're
noticeable as early as 3 years of age. ADHD symptoms can be mild, moderate or
severe, and they may continue into adulthood.

Inattention

A child who shows a pattern of inattention may often:

 Fail to pay close attention to details or make careless mistakes in schoolwork

 Have trouble staying focused in tasks or play

 Appear not to listen, even when spoken to directly

 Have difficulty following through on instructions and fail to finish schoolwork or

chores

 Have trouble organizing tasks and activities

 Avoid or dislike tasks that require focused mental effort, such as homework

 Lose items needed for tasks or activities, for example, toys, school assignments,
pencils

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  Be easily distracted

 Forget to do some daily activities, such as forgetting to do chores

Hyperactivity and impulsivity

A child who shows a pattern of hyperactive and impulsive symptoms may often:

 Fidget with or tap his or her hands or feet, or squirm in the seat

 Have difficulty staying seated in the classroom or in other situations

 Be on the go, in constant motion

 Run around or climb in situations when it's not appropriate

 Have trouble playing or doing an activity quietly

 Talk too much

 Blurt out answers, interrupting the questioner

 Have difficulty waiting for his or her turn

 Interrupt or intrude on others' conversations, games or activities

Causes

While the exact cause of ADHD is not clear, research efforts continue. Factors that
may be involved in the development of ADHD include genetics, the environment or
problems with the central nervous system at key moments in development.

Risk factors

Risk factors for ADHD may include:

 Blood relatives, such as a parent or sibling, with ADHD or another mental health
disorder

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  Exposure to environmental toxins — such as lead, found mainly in paint and
pipes in older buildings

 Maternal drug use, alcohol use or smoking during pregnancy

 Premature birth

Although sugar is a popular suspect in causing hyperactivity, there's no reliable proof

of this. Many issues in childhood can lead to difficulty sustaining attention, but that's
not the same as ADHD.

Complications

ADHD can make life difficult for children. Children with ADHD:

 Often struggle in the classroom, which can lead to academic failure and judgment
by other children and adults

 Tend to have more accidents and injuries of all kinds than do children who don't
have ADHD

 Tend to have poor self-esteem

 Are more likely to have trouble interacting with and being accepted by peers and
adults

 Are at increased risk of alcohol and drug abuse and other delinquent behavior

Prevention

To help reduce your child's risk of ADHD:

 During pregnancy, avoid anything that could harm fetal development. For
example, don't drink alcohol, use recreational drugs or smoke cigarettes.

 Protect your child from exposure to pollutants and toxins, including cigarette
smoke and lead paint.
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  Limit screen time. Although still unproved, it may be prudent for children to
avoid excessive exposure to TV and video games in the first five years of life.

Treatment

 Stimulant medications
Examples include:

- Amphetamines. These include dextroamphetamine

- Methylphenidates. These include methylphenidate

 ADHD behavior therapy

Examples of therapy include:

 Behavior therapy. Teachers and parents can learn behavior-changing strategies,

such as token reward systems and timeouts, for dealing with difficult situations.

 Social skills training. This can help children learn appropriate social behaviors.

 Parenting skills training. This can help parents develop ways to understand and
guide their child's behavior.

 Psychotherapy. This allows older children with ADHD to talk about issues that
bother them, explore negative behavior patterns and learn ways to deal with their
symptoms.

 Family therapy. Family therapy can help parents and siblings deal with the
stress of living with someone who has ADHD.

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 Cerebral palsy

Prepared by

Dr. Eman Hassan

297
 Cerebral palsy
Definition
Cere bral palsy is defined as a non progressive disorder of cerebral function
involving posture and movement, dating to events in the prenatal, natal, or neonatal
period. It is often associated with epilepsy and abnormalities of speech, vision and
intellect resulting from a lesion or defect of the developing brain.
The incidence of cerebral palsy is 4/1000 population.
Causes of cerebral palsy
1- Antenatal causes
a) Intra-uterine infections: TORCH.
b) Fetal anoxia, maternal hemorrhage, placental insufficiency.
c) Maternal irradiations of the pelvis.
d) Congenital malformations of brain or vascular occlusion.
2- Intranatal causes
a) Birth injury: intracranial hemorrhage, cerebral trauma.
b) Cerebral anoxia.
c) Marked how birth weight infants and prematurity.
3- Postnatal causes
a) Intra-cranial infections: meningitis, encephalitis, brain abscess.
b) Neonatal asphyxia.
c) Kernicterus.
d) Hypoglycemia.
Signs and symptoms

 Variations in muscle tone, such as being either too stiff or too floppy
 Stiff muscles and exaggerated reflexes (spasticity)
 Stiff muscles with normal reflexes (rigidity)
 Lack of muscle coordination
 Tremors or involuntary movements
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  Slow movements
 Delays in reaching motor skills milestones, such as pushing up on arms,
sitting up alone or crawling
 Favoring one side of the body, such as reaching with only one hand or
dragging a leg while crawling
 Difficulty walking, such as walking on toes, a scissors-like gait with
knees crossing or a wide gait
 Problems with swallowing
 Difficulty with sucking or eating
 Delays in speech development or difficulty speaking
 Difficulty with precise motions, such as picking up a crayon or spoon

Other neurological problems

 Difficulty with vision and hearing

 Intellectual disabilities
 Seizures
 Abnormal touch or pain perceptions
 Oral diseases
 Mental health (psychiatric) conditions
 Urinary incontinence

Types of cerebral palsy

1- Spastic cerebral palsy: is the most common type.
a- Spastic hemiplegia: manifestations of upper motor neuron lesion are
present. The arm is often more involved than the leg. Walking is delayed
b- Spastic diplegia: refers to affection of the 4 limbs but lower limbs are
more affected than the upper with bilateral spasticity

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 c- Spastic quadriplegia: is the most severe form of cerebral palsy because of
marked motor impairment of all extremities and high association with mental
retardation and seizures. Speech and visual abnormalities are common.
d- Spastic monoplegia and paraplegia: may also occur.
2- Extrapyramidal cerebral palsy: it is relatively rare especially after improved
prevention of kernicterus. These infants are characteristically hypotonic with poor
head control.
3- Ataxic cerebral palsy: it is due to perinatal asphyxia affecting the cerebellum. It is
characterized by hypotonia, intention tremors and ataxic gait.
4- Mixed types
Diagnosis
Thorough history and physical examination should be performed to eliminate
progressive disorders of the CNS.
 The diagnosis depends on the severity and the nature of the neurologic
abnormalities.
 A baseline electroencephalogram (EEG) and CT scan may be indicated to
determine the location and extent of the structural lesion or associated
congenital anomalies.
 Tests of hearing and visual function should be performed.
Prevention
Prevention of cerebral palsy is the ideal approach of this problem and is accomplished
through:
1. Prevention of maternal irradiation and unnecessary drug intake.
2. Antenatal monitoring to prevent intrapartum asphyxia.
3. Prevention of birth trauma and perinatal asphyxia.
4. Prevention of hypoglycemia.
5. Prevention of low birth weight and its complications.
6. Proper management of neonatal jaundice.

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Early diagnosis is necessary in order to try to prevent secondary positional
deformities.
Treatment
 Physiotherapy: prevents gross contractures. Serial plastering and splinting are
required to treat positional deformity.
 Reducing abnormal muscle tone: small regular does of benzodiazepine may be
useful in reducing the severity of spasticity.
 Surgical procedures: to improve the mobility.
 Speech therapy and hearing aids may be useful if there is deafness.
Nursing Care for Cerebral Palsy:
Impaired Physical Mobility related to decreased muscle strength
 Plan activities to use fine motor skills like hand activities.
 Perform range of motion exercises every 4 hours.
 Sitting, balancing, crawling, and walking are encouraged.
 Employ aids such as parallel bars and crutches.
Imbalanced nutrition: Less than body requirements related to motor problems
 High expenditure of calories with the intense movements and feeding difficulty
leads to a calorie deficit.
 High caloric, high roughage diet is advised.
 Teach family techniques to promote calorie and nutrient intake.
 Position the child upright for feeding.
 Place foods far back in the mouth to overcome tongue thrust.
 Use soft foods in small amounts.
 Allow extra time for chewing and swallowing.
 Assist with jaw control during feeding or facilitate eating.
Risk for Injury
 Provide safe physical environment.

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  Use padded furniture for protection; Do not use pillows because it may cause
suffocation.
 Use side rail on bed to prevent falls.
 Use sturdy furniture that does not slip.
 Ensure that the toys are safe.
 Apply seat belts.
Impaired verbal communication related to hearing loss
 Speech therapist.
 Talk to child slowly, give eye contact, non verbal communication through
pictures, flashcards, and talking boards.

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Mental retardation

Prepared by

Dr. Eman Hassan

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 Mental retardation

Definition
Mental retardation is defined as limitations in performance due to impairments in
measured intelligence and adaptive behavior.

Intelligence: is a multi-factorial mental process of abstract of thinking, visual,

auditory, memory, verbal expression and manipulative capacities.

Impaired intelligence from early life leads to inadequate mental development

throughout growth period. Intelligence is usually expressed in term of intelligence
quotient (IQ).

IQ = Mental age x 100 (Normal IQ = 90-110)

Chronologic age

Prevalence of mental retardation is

Mental retardation presents in general population 2 – 3 % children. About 3/4 of the
total cases are only mild type and 5 % are having severe to profound mental
retardation.
Classification
According to the degree of mental retardation
Table: Classification by the degree of mental retardation
Degree IQ Prognosis
* Borderline * 68 - 83 * Educational problem, self care
* Mild * 51 - 70 * Educable in special class, self care
* Moderate * 36 - 50 * Trainable ,self care

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 * Severe *21 – 35 * Non- trainable, minimal self care,
need much supervision
* Profound * 20 * Non- trainable, need total
supervision

Etiological classification (predisposing factors)

1- Genetic
a. Chromosomal abnormalities (Down syndrome)
b. Metabolic disorder
c. Cerebral degeneration disorder
d. Structural disorder or congenital anomiles (e.g. genetic microcephaly,
hydrocephalus).
2- Intrauterine
a. Congenital infections e.g. rubella toxoplasmosis.
b. Drugs and toxins e.g. phenytoin, alcohol, tobacco.
c. Radiation
d. Placental insufficiency
3- Perinatal
a. During pregnancy: ante-partum hemorrhage, toxemia.
b. During labor: asphyxia, trauma, intracranial hemorrhage
4- Neonatal
a. Intracranial hemorrhage, intracranial infections, hypoglycemia, kernicterus.
5- Postnatal
1-Trauma: e.g. intracranial hemorrhage.
2- Infections: e.g. encephalitis, meningitis.
3- Anoxia: e.g. asphyxia, status epilepticus.
4- Metabolic: e.g. hypoglycemia.
5- Endocrine: e.g. hypothyroidism.
6- Poisoning: e.g. lead, copper.

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Clinical picture
Delayed achievement of development milestones is the cardinal symptom of mental
retardation
In infancy:
The main clinical finding is:-

- Delayed social development (delayed social smile, and delayed recognition of the
mother).
- Poor feeding (weak or uncoordinated sucking leading to poor weight gain).
- Delayed or decreased visual and auditory response
- Reduced spontaneous activity.
- Delayed head and trunk control (hypotonia, or spastic muscle tone).
In early childhood:
The most important feature is:-
- Delayed speech and language disabilities
- Delayed standing and walking (usually associated with delayed sphincter control)
- Failure to achieve independence (self-feeding, dressing and toilet training)
- Short attention span and hyperactivity, poor memory, poor concentration
- Sleep problems and convulsion.
In late childhood:
The main manifestations are:
- School failure or underachievement and learning difficulties.
Diagnosis
* Delayed development milestones suggest the diagnosis
* Detailed history, examination (physical, neurological and IQ test), and investigation
are required to find the cause of mental retardation ( urine test, chromosomal studies,
hormonal assay, enzyme estimation, serological test, CSF study, X- ray skull,, EEG,
CT scan and MRI. In some cases no cause can be identified.

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Conditions that may be confused with mental retardation are: cerebral palsy,
blindness, deafness, and social deprivation.
Prevention of mental retardation
1- Prevention of delivery of retarded children:
a. Vaccination of all females against rubella before child bearing period.
b. Inuntreatable inherited disorders, avoid further pregnancies, especially when the
recurrence risk is high
c. Avoidance of conditions that may lead to acquired retardation during intrauterine
perinatal and postnatal periods.
2- Early diagnosis and treatment of preventable / treatable conditions e.g.
congenital hypothyroidism, galactosemia and phenylketonuria by suitable screening
tests.
Management of mental retardation
1- in treatable conditions, the specific therapy will prevent further impairment of
mental abilities.
- Congenital hypothyroidism requires life long therapy with thyroid hormone
- Galactosemia requires elimination of galactose from the diet and using galactose –
free diet.
2- In untreatable conditions management is supportive:
a. Treatment of associated problems e.g. epilepsy or hearing defect.
b. Education and training according to the degree of mental retardation.
c. Emotional support to the family.
d. institutionalization for the profoundly retarded children.

General Nursing care

1. The nurse helps family adjust to the Diagnosis. By:-
* Provide opportunity for family to adjust to discovery of diagnosis.
* Anticipate the usual grief reaction to loss of the perfect child.
* Explore family's feeling regarding child and their ability to cope with the
discover.
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* Encourage family to express their concerns.
* Repeat information as often as necessary.
* Serve as a role model regarding attitude and behavior toward child.
2. Increase Family's Understanding of the Discover. By:-
* Help family to understand the disorder, and implications.
* Reinforce information given by others.
* Clarify misconception.
* Provide accurate information at family can absorb.
* Discuss advantages and limitations of therapeutic plan.
3- Reduce family's fears and anxieties. By:-
* Explore family's concerns and feeling of irritation, guilt, anger, disappointment,
inadequacy.
* Help family distinguish between realistic fears and un founded fears, eliminate
unfounded fears
* Discuss with parents their fear regarding.
- Dealing with child's anxiety about condition.
- Fear of dreadful development.
- Fear of death.
- Fear of tests and procedures.
- Child's ability to compete with peers.
4- Promote Family's Ability To Provide Child's Care By:-
* Help family develop a thorough plan of care.
* Teach skills needed to provide optimum care.
* Interpret Child's behavior to parents (e.g., anger, depression, regression,
physical modification as result of disorder.
* Help family plan for the future.
5- Support Family Siblings of Affected Child by:-
* Assess siblings to identify areas of concern.
* Communicate honestly with siblings about child's disease or disability.
* Provide opportunity for siblings to ask questions and express feelings but avoid.
* Encourage parents to spend special time with their children who are not ill or
disabled.
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Congestive heart
failure

Prepared
by

Dr. Eman Hassan

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 Congestive heart failure

Congestive heart failure is a condition in which the heart cannot adequately pump
blood. Because the pumping action of the heart is reduced, blood backs up into certain
body tissues, causing fluid buildup.

What is going on in the body?

Congestive heart failure is caused by a variety of complex problems that cause the
pumping chambers of the heart to fail.

The heart is divided into a left heart and a right heart. The blood receives oxygen as it
passes through the lungs. The left heart receives blood from the lungs and pumps this
oxygen-rich blood to the organs, muscles, and tissues of the body. The right heart
receives oxygen-poor blood from these organs and tissues. It then pumps it to the
lungs to receive a fresh supply of oxygen.

If the pumping chambers of the heart do not function properly, blood stays in the
lungs or in the tissues of the body. This leads to congestion of these areas with blood
and fluid, the reason for the term congestive heart failure. The organs and tissues do
not receive an adequate supply of blood, and they begin to suffer the effects.

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The causes and risks of the condition

The most common cause of congestive heart failure in children is congenital heart
disease, including:

Cardiac malformations, such as tetralogy of Fallot

Abnormalities of the heart valves
Under development of one or both ventricles
Coarctation of the aorta, which is a narrowing of the vessel bringing blood to the
heart
Ventricular septal defects or holes in the walls that separate the left and right sides
of the heart
Patent ductus arteriosus, or an abnormal connection between the aorta and the
pulmonary artery that mixes oxygenated and unoxygenated blood

Other causes of congestive heart failure in children include:

Rheumatic heart disease, caused by damage to the heart from group A strep
infections
Bacterial endocarditis or inflammation of the lining of the heart due to an infection
Myocarditis or inflammation of the heart muscle
Complications of open heart surgery
Chronic anemia, which results in a low red blood cell count
Poor nutrition
Drug toxicity

Symptoms & Signs

Most of the time, congestive heart failure occurs quickly in children. Failure of both
ventricles is common. This causes a combination of symptoms, including:

Shortness of breath

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 Rapid breathing
A rapid heartbeat
Coughing and wheezing
Irritability
Failure to thrive, meaning that the child's growth and weight gain are slower than
expected
Excessive sweating
Loss of appetite
Swelling of the hands and feet
Pain and tenderness of the abdomen
Coolness of extremities to the touch
Grayish tint to the skin

Diagnosed

Congestive heart failure is diagnosed on the basis of the child's medical history and
physical exam. Identification of the underlying disease may require special tests,
including:

Electrocardiogram, or ECG, which graphs the electrical activity of the heart

Chest X-ray, which may reveal an abnormally enlarged heart
Echocardiography, which uses ultrasound waves to provide information about the
structure, function, and motion of the heart
Cardiac catheterization, which involves injection of a contrast agent to allow the
doctor to watch the blood flow through the heart and its arteries
Complete blood count, renal function, blood gas analysis, blood culture.

Prevention

- Prompt treatment of the underlying disease can lower the child's risk of
developing congestive heart failure.

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 - Maintaining a healthy body weight, including physical activity in everyday life,
and eating a diet designed to minimize heart disease can help minimize
congestive heart failure.
- Check and observe the child continuously.

Long-term effects of the condition

If untreated, congestive heart failure in children can lead to early death. Long-term
effects may include delays in the child's development and permanent damage to
organs such as the brain, liver, and kidneys.

Treatment & Monitoring

- Giving oxygen
- Limiting sodium in the diet
- Treating underlying anemia.
- A heart medication called digitalis can be used to help improve the
efficiency of the heart. Water pills help relieves some of the pressure on the
heart by removing extra fluid.
- In severe cases, stronger heart medications can be used to help the heart
pump with more forceful contractions. Medications that relax the blood
vessels can also be used. If the cause of CHF is congenital heart disease,
open heart surgery may be done.

Nursing care
- Monitor respiratory rate (↑ RR), rhythm and character every hourly. Be alert to
increased respiratory rate; observe use of accessory muscles of respiration.
- Auscultate breath sounds and lung fields for noting crackles, wheezes, rhochi
and other sounds.
- Provide supplemental oxygen to maintain O2 saturation to >95% by tend or by
nasal catheter.

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- Assess ABGs; note changes in response to O2 supplementation or treatment of
altered heamodynamics.
- Suction secretions, as needed.
- Encourage deep breathing, coughing q24.
- Place in propped up position to maximize chest excursion.
- Monitor intake and output. Report positive fluid state or decreased urine output.
- Check weight properly daily and report changes.
- Observe for weight gain, oedema and murmures.
- Check heart sounds.
- Administer antibiotics, as prescribed, according to the cause.
- Administer diuretics (usual drug is frusemide in a dose 1 – 3 mg/kg orally or 0.5
– 1.5 mg parentally.
- Observe for potassium deficiency.
- Limit oral fluids.
- Maintain prescribed activity level.
- Administer digoxin as prescribed.
- During digitalization, one half of the total calculated doses should be given
state. Divide the remaining dose into two halves and administer at 8 hours
intervals.
- Digitalis must be used carefully to avoid toxic effects.
- Check the heart rate correctly to identify complications.
- Organize nursing activities so that rest periods are provided properly.
- Assist in laboratory investigations.

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 Rheumatic Fever
Acute rheumatic fever is a systemic disease of childhood, often recurrent that
follows group A beta hemolytic streptococcal infection. It is an inflammatory
disease of connective tissue, primarily involving heart, blood vessels, joints, and
CNS

Epidemiology

1. Ages 5-15 years are most susceptible

2. Girls > boys
3. Common in 3rd world countries
4. Environmental factors-- overcrowding, poor sanitation, poverty,
5. Incidence more during winter & early spring
Pathogenesis
 Delayed immune response to infection with group. A beta hemolytic
streptococci.
 After a latent period of 1-3 weeks, antibody induced immunological damage
occur to heart valves, joints, subcutaneous tissue & basal ganglia of brain
Clinical Features
The symptoms of rheumatic fever usually start about one to five weeks after your
child has been infected with streptococcus bacteria. The following are the most
common symptoms of rheumatic fever. However, each child may experience
symptoms differently. Symptoms may include:

 Joint inflammation. This includes swelling, tenderness and redness over

multiple joints. The joints affected are usually the larger joints in the knees
or ankles. The inflammation "moves" from one joint to another over several
days.
 Small nodules or hard, round bumps under the skin

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  A change in your child's neuromuscular movements. (This is usually noted
by a change in your child's handwriting and may also include jerky
movements.)
 Rash. A pink rash with odd edges that is usually seen on the trunk of the
body or arms and legs.
 Fever
 Weight loss
 Fatigue
 Stomach pains
 Symptoms of rheumatic fever may resemble other medical conditions.
Always consult a doctor for a diagnosis.
Diagnosis

The diagnosis of rheumatic fever can be made when two of the major criteria, or
one major criterion plus two minor criteria, are present along with evidence of a
streptococcal infection.

There is no definitive test to diagnose rheumatic fever. Blood work is also usually
done to assist in making a diagnosis. Child's doctor may also order an
electrocardiogram (a test that records the electrical activity of the heart, shows
abnormal rhythms — arrhythmias or dysrhythmias — and detects heart muscle
damage of the heart) as part of the diagnostic process for rheumatic fever.

A throat culture may also be done to determine if the child tests positive for
streptococcus bacteria, although during the initial phase of rheumatic fever, the
throat culture is often negative.
Major criteria include:
1.Arthritis
 involving major joints

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  Commonly involved joints-knee, ankle, elbow & wrist
 Occur in 80%,involved joints are finely tender
 Arthritis do not progress to chronic disease
2.Carditis
 Manifest as (endocarditis, myocarditis and pericarditis),occur in 40-50% of
cases
 Carditis is the only manifestation of rheumatic fever that leaves a permanent
damage to the organ
3. Chorea
 Occur in 5-10% of cases
 Clinically manifest deterioration of handwriting, emotional liability or
grimacing of face
4. Erythema Marginatum
 Occur in <5%.
 Pale center with red irregular margin
 More on trunks & limbs & non-itchy
 Often associated with chronic carditis
5. Subcutaneous nodules
 Occur in 10%
 Painless, pea-sized, palpable nodules
 Mainly over extensor surfaces of joints, spine, scapulae & scalp
Minor criteria include:
 Fever
 Arthralgia (pain in one or more joints)
 Previous rheumatic carditis (inflammation of the heart)
 Changes in the electrocardiogram pattern
 Abnormal sedimentation rate or C-reactive protein (laboratory tests
performed on blood)

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Laboratory Findings
 High ESR
 Anemia, leucocytosis
 Elevated C-reactive protien
 Throat culture
 ECG

 2D Echo cardiography- valve edema, mitral regurgitation, lift atrium & lift
ventricle dilatation, pericardial effusion, decreased contractility

What is the treatment for rheumatic fever in children?

Specific treatment for rheumatic fever will be determined by your child's doctor
based on:

 Child's overall health and medical history

 Child's tolerance for specific medications, procedures or therapies
 Expectations for the course of the reaction
 Children with rheumatic fever are often treated in the hospital, depending on
the severity of the disease.
Treatment for rheumatic fever, in most cases, combines the following three
approaches:

 Treatment for streptococcus infection. The immediate goal is to treat the

infection with antibiotics. This is done even if the throat culture is negative.
Following the initial treatment for strep infection, your child may continue to
receive monthly doses of antibiotics to help prevent further complications.
 Anti-inflammatory medications. Based on the severity of your child's
condition, your child's doctor may prescribe medications to help decrease the
swelling that occurs in the heart muscle, as well as to relieve joint pain.

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  Bed rest. The length of bed rest will be determined by your child's doctor,
based on the severity of your child's disease and the involvement of the heart
and joints. Bed rest may range from two to 12 weeks.

Nursing Management

Nursing care of a child with rheumatic fever include:

Nursing Assessment

Nursing assessment for a child with rheumatic fever are as follows:

 History. Obtain a complete up-to-date history from the child and the
caregiver; ask about a recent sore throat or upper respiratory infection; find
out when the symptoms began, the extent of the illness, and what if any
treatment was obtained.

 Physical exam. Begin with a careful review of all systems, and note the
child’s physical condition; observe for any signs that may be classified as
major or minor manifestations; in the physical exam, observe for elevated
temperature and pulse, and carefully examine for erythema marginatum,
subcutaneous nodules, swollen or painful joints, or signs of chorea.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

 Acute pain related to joint pain when extremities are touched or moved.

 Deficient diversional activity related to prescribed bed rest.

 Activity intolerance related to carditis or arthralgia.

 Risk for injury related to chorea.

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  Risk for noncompliance with prophylactic drug therapy related to financial
or emotional burden of lifelong therapy.

 Deficient knowledge of caregiver related to the condition, need for long-

term therapy, and risk factors.

Nursing Care Planning and Goals

Main Article Acute Rheumatic Fever Nursing Care Plans

The major nursing care planning goals for rheumatic fever are:

 Reducing pain.

 Providing diversional activities and sensory stimulation.

 Conserving energy.

 Preventing injury.

Nursing Interventions

Nursing interventions for a child with rheumatic fever include:

 Provide comfort and reduce pain. Position the child to reduce joint pain;
warm baths and gentle range-of-motion exercises help to alleviate some of
the joint discomforts; use pain indicator scales with children so they are able
to express the level of their pain.

 Provide diversional activities and sensory stimulation. For those who do

not feel very ill, bed rest can cause distress or resentment; be creative in
finding diversional activities that allow bed rest but prevent restlessness and
boredom, such as a good book; quiet games can provide some entertainment,
and plan all activities with the child’s developmental stage in mind.

 Promote energy conservation. Provide rest periods between activities to

help pace the child’s energies and provide for maximum comfort; if the child
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 has chorea, inform visitors that the child cannot control these movements,
which are as upsetting to the child as they are to others.

 Prevent injury. Protect the child from injury by keeping the side rails up and
padding them; do not leave a child with chorea unattended in a wheelchair,
and use all appropriate safety measures.

Evaluation
Goals are met as evidenced by:

 Reducing pain.

 Providing diversional activities and sensory stimulation.

 Conserving energy.

 Preventing injury.

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Nephrotic Syndrome

Prepared by

Dr. Eman Hassan

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 Nephrotic Syndrome
(Nephrosis)
Definition:
Nephrotic Syndrome (NS) in children is a common chronic disorder and serious
medical condition, characterized by alterations of the glomerular capillary wall,
resulting in
 Albuminuria
 Hypoalbuminemia
 Hyperlipidemia
Pathophysiology of nephrotic syndrome:-

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Incidence:-
Approximately 80% of children with NS have a type of primary disease called
minimal change nephrotic syndrome (MCNS) which incidence of 3 per 100.000
children. The annual incidence of Nephrotic Syndrome in Egypt ranged between 0.03
- 0.05 % of children presented to the Pediatric Nephrology Clinic, Ain Shams
University.
Epidemiology:
- Age > 3 years, usually 2-7 years.
- Boys more than girls
Types:-

- Primary nephrotic Syndrome (Idiopathic) or minimal change nephrotic

syndrome results from a disorder within the glomerulus of the kidney and is the
common type seen in children and representing more than 90 percent of cases before
10 years of age and 50 percent after 10 years of age .

- Secondary nephrotic syndrome can acquire as the result of systemic disease

such as; systemic lupus erythematosus, heavy metal poisoning, and cancer.

- Congenital nephrotic syndrome is an autosomal recessive disease caused by

mutations in a major podocyte protein, Infants who have nephrotic syndrome are small
for gestational age, proteinuria and edema are manifested early. The disease dose not
responds to the usual therapy, and death in the first year of life

Clinical Manifestations:
 Edema
The characteristic symptom of nephrotic syndrome is edema. This occurs
slowly; the child does not appear to be sick. It is noticed at first about the
eyes and ankles but later generalized.
 Weight gain

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 The child weight gains because of the accumulation of the fluid, the
abdomen may become so distended.
 The child is
- Pale - Irritable - Restless
- Poor appetite.
- The child becomes more susceptible to infection
 Anorexia & malnutrition.
 Vomiting & abdominal distention.
 ↓ Urinary out put due to edema.
 Pain and respiratory difficulty due to ascites, pleural effusion and
pulmonary edema.
 Diarrhea due to edema of intestinal wall.
 Bp is normal or slightly↓
 The child is febrile & irritable.
Causes:
The main cause is unknown. It depends on clinical and microscopic finding, as
different types of nephrotic syndrome differ in their clinical course, response to drugs
and prognosis.
Complications:-
1-Increase susceptibility to infection due to:-
(Edema fluid is a good culture medium).
 Hypoproteinemia.
 ↓ Immunoglobulin levels
 ↓ Splenic function.
 ↓ Bactericidal activity of leukocytes
 Immunosuppressive therapy.
The most common site of infection is peritonitis.
2- Arterial or venous thrombosis
3- Acute or Chronic kidney failure
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 4- High blood cholesterol and elevated blood triglycerides
5- Poor nutrition :- Loss of too much blood protein can result in malnutrition.
Treatment:
1- Hospitalization & investigations
 Physical examinations
 Tuberculin test, chest x- ray.
 Urine culture.
 Vital signs.
 Daily monitoring of weight.
2- Physical activity as tolerated by child.
3- Restriction of salt and water if edema is sever.
4- Diuretics → in case of sever edema.
5- Specific therapy:-
• Prednisone 2 mg/kg/ day given in 3- 4 divided doses for 4 weeks then start
alternate day therapy for 3-6 months.
Nursing care:-
1) Edema: -
- Skin should be dry & clean.
- Skin care to the edematous area.
- Change position frequently.
2) Weighing the child every day at the same time.
3) Well balanced and complete diet is given with:
- Limit salt intake for short time.
- Protein is given according to the degree of dysfunction of the kidney.
- Intake and output chart
4) Ascites: -
- The child should be put in semi- sitting position → to facilitate
breathing.
- The nurse should be ready to help in paracentesis procedure if ordered.

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 - The child should void before the procedure.
- Observe and chart child's condition, amount and color of drainage.
5) Heart failure: -
- Activity is restricted, the child is put in semi-setting position and O2
therapy is given.
6) Protect the child from infection by:
- Keeping him warm & dry and don't expose him to infected persons
- Use good hand washing and aseptic technique.
7) Emotional support to parents and child and allow parents to visit the child.
8) Health teaching to parent on discharge about.
- Diet. - Medication given.
- Prevention of infection. - Skin care.
- Follow up. - Frequent urine analysis for protein.
The objectives of the nursing care for children with NS start with education of
the mother regarding the chronic relapsing and remitting nature of the disease, as
well as the need for compliance with medications.
The child’s family goals include:
 Instructing about the disease and treatment.
 Learning ways to cope with the child’s long term care.
 Routine medical follow up care

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 Musculoskeletal system disorders
Objectives:
 Describe pediatric differences in the musculoskeletal system from those of an
adult
 Define common musculoskeletal system disorders
 Describe common pediatric musculoskeletal system disorders
 List the home instruction needed for an infant in a Pavlik harness
 Discuss the nursing measures for a child in a cast
 Formulate a nursing care plan for the adolescent confined in a brace for the
treatment of scoliosis

Introduction
Bones, joints, muscle, and cartilaginous tissue make up the musculoskeletal
system. Beginning in the fetus, embryonic connective tissue develops into cartilage,
which converts into bone. This process, called ossification, continues until the child is
about 20 years of age.
At birth infants have all their muscle
tissue, and growth affects the size of the
muscle but not the number. Bones are largely
cartilage in the infant, which makes them more
flexible. It is unusual for children younger than
1 year of age to have fractures. As the child
grows, secondary ossification of the long
bones occurs causing them to be less dense and
more porous. This explains why older children
have a higher risk of fractures.
The infant’s skull is not rigid, has
flexible suture lines, and has two openings

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(anterior and posterior fontanels). The posterior fontanel closes at 6 to 8 weeks, and
the anterior fontanel closes at 16 to 18 months to allow for growth of the brain.
The periosteum is the covering of the bone. It contains blood vessels, nerve
fibers, and lymphatic vessels. In the young child, this covering is stronger and tougher
to allow the child to absorb more force trauma before the bone breaks. The rich
periosteum also assists in the fast healing process seen in children. The growth of long
bones occurs in the epiphyseal plates. Any injury or fracture of these plates can result
in disturbed bone growth.
Function of the Musculoskeletal System:
 Protection
 Support
 Motion
 Storage of minerals
 Manufacture red blood cells

Pediatric Differences in MSK:

- Skeletal growth is most rapid during infancy and adolescence.
- The bones of children are more resilient, tend to bend, and may deform before
breaking.
- Bone healing is rapid growing in children because of the thickened periosteum,
blood supply to bone is rich and osteogenic activity is high, so fractures heal in
less time in children than in adults.
- Epiphyseal plate fractures in children can disrupt the growth of bones.
Musculoskeletal disorders can be either acquired or congenital. The impact of these
disorders on the child’s movement can influence the child’s development. In children,
a wide variety of disorders affect the muscles, joints, and bones. These disorders may
be caused by heredity, injury, inflammation, or infection.

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Common musculoskeletal system disorders
Rickets: it is a skeletal system disease that causes bowed legs in children due to
deficiency of vit. D and calcium.
Developmental dysplasia of the hip (DDH) is a common orthopedic deformity. It is
an abnormal formation of the hip joint in which the femoral head is not stable
in the socket (acetabulum). Also, the ligaments of the hip joint may be loose
and stretched
Clubfoot, one of the most common congenital deformities of the skeletal system, is
characterized by a foot that has been twisted inward or outward or toes higher
or lower than the heel (Figure 1). These deformities can vary from mild and
flexible to severe and rigid. The incidence rate is about 1 in 1000 births, with
boys affected twice as often as girls.

FIGURE 1: The child with clubfoot has a flexed ankle, a turned heel, and an adducted forefoot.

Scoliosis: it is a skeletal disease in which the spin is curved from side to side like
alphabet 's'. the disorder become apparent during adolescence and usually
affects girls more than boy.

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Kyphosis: - Excessive convex curvature of thoracic spine or hunchback
Lordosis: - Excessive concave curvature of lumbar spine, or sway back

Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) is a common orthopedic deformity.

It is also known as Congenital Dislocation of hip (CDH) or Hip Dysplasia. The
term hip dysplasia is a broad description applied to various degrees of deformity that
may involve subluxation or dislocation and may be either partial or complete. The
head of the femur is partially or completely displaced from a shallow hip socket
(acetabulum). Both hereditary and environmental factors appear to be involved in the
cause. Hip malformation, joint laxity, breech position, and race may all contribute.

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DDH is seven times more common in girls than in boys. Newborn infants seldom have
complete dislocation. When the infant begins to walk, the pressure exerted on the hip
can cause a complete dislocation. Accordingly, early detection and treatment are of
particular importance in this condition.
Definition :
Developmental Dysplasia of Hip (DDH) is a congenital or acquired deformation
or misalignment of the hip joint. It is an abnormal formation of the hip joint in which
the femoral head is not stable in the socket (acetabulum). Also, the ligaments of the
hip joint may be loose and stretched.

Hip dysplasia can range from barely detectable

to severely malformed/ dislocated hip. The
condition can be:
 Bilateral dysplasia, if both hip joints are
affected.
 Unilateral dysplasia, one joint only shows
deformity
Degrees of Developmental Dysplasia of Hip
There are 3 degrees of Developmental Dysplasia of Hip
 Acetabular dysplasia or preluxation: This is the mildest form of DDH,
in which the acetabulum cavity or hip socket is too shallow or deformed.
The femur head remains in the acetabulum in this type.

 Subluxation: it accounts the largest percentage of DDH, subluxation,

means incomplete dislocation of the hip. The femoral head remains in
contact with the acetabulum cavity, but is displaced

 Complete Dislocation or luxation: in this type, there is no contact

between the head of femur and acetabulum cavity. There is a complete
loss of contact between the femur head and acetabulum.

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Incidence and Etiology:
 Developmental Dysplasia of Hip occurs in 1-2 / 1000 live births, and
approximately 15% to 50% of infants with DDH are born breech.
 It is eight times more common in females than males.
 Bilateral involvement is present in about 50% of the cases.

The cause of Developmental Dysplasia of Hip is multifactorial and includes

physiological, mechanical and genetic factors:
 Physiological factor includes maternal hormone estrogen, the production of
which is increased towards the end of pregnancy leading to greater pelvic laxity
of mother. Increased estrogen affects the fetal joints. Female infants react more
to estrogen; hence the defect is more common in girls.
 Mechanical factors include abnormal intrauterine position of the fetus, breech
presentation and large size of the fetus.
 Genetic factors: positive family history that contribute to Developmental
Dysplasia of Hip.

Clinical features

Clinical features of Developmental Dysplasia of Hip depend upon the age of

the child.
Clinical features in infants are:

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 o Subluxation of the hip is commonly discovered at the time of the newborn
examination.
o Shortening of legs
o Asymmetry of legs
o The knee on the side of the dislocation appears to be shorter and the skin folds
of the thigh are often asymmetrical. When the infant is prone, one hip is higher
than the other Asymmetry of gluteal folds of skin, when infant is placed
in prone position (Figure 2).
o Limited abduction of the leg on affected side.
o Apparently short femur on affected side.
o After 3 months of age, the affected leg may turn outward or become
shorter than other leg.
o In some infants younger than 4 weeks of age, the physician can
actually feel and hear the femoral head slip into the acetabulum under
gentle pressure. This is called Ortolani’s sign or Ortolani’s click and
is considered diagnostic.

Figure 2: Three classic signs of DDH. A and B, Unequal skin folds; C, limitation of abduction;
and D, unequal knee height.

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Clinical features in older children are:
o Unequal length of leg
o Gait abnormalities such as toe walking or limping may be present.
o Galeazzi sign is seen, it is demonstrated by placing both hips at 90
degree of flexion and comparing the height of knees and looking for
asymmetry (Figure 3).

Figure 3: Galeazzi sign, the child is positioned as shown. The knee is lower on the affected side
because of posterior displacement in the developmentally dysplastic hip (arrow).

Diagnostic Evaluation
1) The Ortolani and Barlow tests (Figure 4) are most reliable from birth to 4 weeks
of age.
 Barlow maneuver identifies a dislocated hip that can be reduced and detects
the hip sliding out of the acetabulum
 Ortolani maneuver is a test used to identify an unstable hip that can be
passively dislocated and detects the hip sliding back into the acetabulum.
Each hip is examined separately. Both maneuvers begin with the infant supine
and the hips and knees flexed to 90° (the feet will be off the bed).

 the Barlow maneuver, the examiner adducts the hip while applying a
posterior force on the knee to cause the head of the femur to dislocate
posteriorly from the acetabulum. A palpable clunk may be detected as the
femoral head exits the acetabulum.
 the Ortolani maneuver, from an adducted position, the hip is gently
abducted while lifting or pushing the femoral trochanter anteriorly. In a
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 positive finding, there is a palpable clunk as the hip reduces back into
position. Hip examination should occur soon after birth and at every visit
until the child is walking normally.
2) Computed tomography (CT) may be useful to assess the position of the femoral
head relative to the acetabulum after closed reduction and casting
3) Radiographs and ultrasound scans confirm the diagnosis.

Figure 4: Ortolani and Barlow tests

Management
Management is begun as soon as the dislocation is detected and varies with the age of
the child. The goal of management is to form a normal joint by keeping the head of
the femur within the hip socket. This constant pressure enlarges and deepens the
acetabulum, thus correcting the dislocation. The bones of small children are fairly
pliable because they contain more cartilage than bones of adults. Treatment for DDH
depends on the age of the child:

i. From birth to approximately 6 months of age

abduction of the hips is maintained with the use of the Pavlik harness (Figure 5).
The harness is worn full time until stability is attained plus 2 months, then a decrease
in wearing time begins. Weaning time from the harness is gradual until normal hip
function is established by ultrasound or x-ray. After 6 months of age, the failure rate
of Pavlik harness is > 50%, because it is difficult to maintain the increasingly active

336
 and crawling infant in harness. Therefore, for children 6 to 18 months of age, the
Pavik harness is less effective and traction is required.

ii. For children 6 months to 2 years of age

If the dislocation is late diagnosed or has not been detected until the child has begun
to walk, it may be necessary to use traction. This pulls the head of the femur down to
the correct position opposite the acetabulum. the dislocation is reduced with general
anesthesia and a spica cast (Figure 6) is applied to hold the abduction. The length of
time that the child remains in the cast varies according to progress, growth, and the
condition of the cast; however, it is usually from 3 to 4 months. During this time, the
cast may be changed about every 6 weeks.

iii. Children older than 2 years

 surgery is necessary. In this case, open reduction of the dislocation or repair of the
shelf of the hip bone is done.
 A cast is applied after surgery to keep the femur in the correct position.
 After removal of the spica cast, some children may require an abduction brace.
The brace is worn for 4 to 8 weeks, and then only at nighttime for 1 to 2 years.

FIFIGURE 5: The Pavlik

Harness is used to maintain
the hips in a position of FIGURE 6 A spica cast after hip surgery.
flexion and abduction.

Nursing management

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The nursing management aims to:

a) Promoting normal growth and development

o The nurse must make the parents accept that the child may not develop
gross motor skills as their peers, but once the treatment is complete, the
child will develop these skills.
o The family should provide opportunities to the child to develop and practice
motor skills.
b) Maintaining correct position of hip
The parent must be informed about:
o The purpose of splint and its proper use
o Time for which the splint is to be worn
o How to keep hip of the child in abduction, when splints are removed for
physical care
c) Maintaining physical mobility
o The nurse helps the family explore alternatives to assist with mobility like
stroller, wheelchair.
o provide opportunities to the child when they can use their arms and uncasted
leg.
d) Protect skin from irritation
o The nurse informed the caregivers should take the following measures:
o Daily skin care should be washed with mild soap and dried thoroughly.
o Child wear long cotton socks and cotton shirt under the brace.
o Should not use lotions or oils on skin under the straps of brace.
o If the skin becomes red, rub it gently with alcohol.
o Cast edges should be covered with cotton.
o Cast should be protected from soiling by covering the edges around groins
and buttocks with water proof tape.
o Change the diapers frequently and keep the baby clean and dry.
o Change the child's position every 2 hours.
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e) Providing optimum nutrition
o The baby in spica, constipation may occur so fiber rich diet should be given
to the child.
o Fluid intake should be encouraged.
o Provide adequate amount of well-balanced diet, high in protein and low in
calories.

f) Parent support and education

Parents require instruction regarding: -
 The correct use of harness
 Skin care while the infant wears the Pavik harness.
 Parents need assurance that they may hold the infant and provide normal
activity experiences. The child with a long-term disability such as this requires
help in meeting the activities of daily living (ADLs).
 General cast care
- Keep the cast dry, be careful with the cast for the first 1-2 days (can easily
crack or break)
- Elevate the cast above heart level (especially for the first 48 hrs)
- Neurovascular assessment (circulation, movement and sensation) q 15-30
minutes for 2 hrs, then q 1-2 hrs thereafter for first 24-48 hrs. checks them
for signs of poor circulation, which would be indicated by pallor, cyanosis,
swelling, coldness, numbness, pain, or burning
- Avoid getting the cast wet (no swimming, baths, or showers)
- Cover with plastic and waterproof tape to keep dry (if necessary)
- Check the skin around the cast edges for irritation, rubbing, or blistering
- Cleanse the skin just under the cast edges with rubbing alcohol
- Do not pour powder, lotion, oils, or perfume into the cast
- Do not allow the child to place anything inside the cast
- Instruct the parent to contact the provider if…

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 o Foul, unusual odor
o Tingling, burning, numbness
o Fingers or toes swell or turn blue, inability to move
o Drainage through cast
o Sudden, unexplained fever
o Pain that is not relieved
o Cast slippage
o Cast crumbles, cracks or breaks
o Cast becomes wet.
- Turn and position a child in a body cast.
Method
1. Use two people to turn a child in a body cast.
2. Lift the child and place in the prone position.
3. Do not use crossbars between the legs as handles.
4. With the child in the prone position, place a pillow under the chest and
under each leg to prevent pressure on the toes.
5. With a bedpan, support the upper back and legs with pillows so that
body alignment is maintained.

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 Scoliosis
The vast majority of childhood scoliosis is " idiopathic " meaning its cause is
unknown. It usually develops in middle or late childhood, before puberty, and is seen
more often in girls than boys. Idiopathic scoliosis is the most common form of
scoliosis and is present in 2 to 4% of children aged 10 to 16 years.

Genetic factors contribute about one third of the risk of disease development.
Mutations in the genes have been implicated in some cases. Scoliosis is not
preventable, but diagnosis and treatment during a child's growing years is the best
way to prevent an existing problem from getting worse.
Definition
Idiopathic scoliosis is lateral curvature of the spine. In which the spine curves
to the side when viewed from the front

Types of Scoliosis
There are multiple types of scoliosis, classified by age of onset and/or cause. These
include the following:
 Congenital scoliosis is present at birth and caused by vertebrae that are not
properly formed prior to birth. Malformed vertebrae manifest in young
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 children and when their spine begins to grow, it grows in the wrong direction.
Part of a vertebra maybe missing or wedge-shaped, and/or abnormal bony
bridges between two or more vertebrae may be present.

 Infantile scoliosis, occurs in the first years of life and before 3 years of age. It
is more common in boys and may resolve on its own with only observation.
Generally, this type of scoliosis has less of a rotational component than other
types.

 Idiopathic scoliosis is the most common type of scoliosis. This type is seen in
children 11-16 years of age. It is also more common in girls, and they are at
higher risk of progression of the curvature. The term idiopathic refers to any
medical condition that arises spontaneously without a known cause.

 Neuromuscular scoliosis is caused by any of a number of associated disease

processes that affect the neurologic or muscular systems. This may
include cerebral palsy, muscular dystrophy, metabolic diseases, and connective
tissue disorders. The age of onset is variable and depends on the disease
process.

Symptoms and Signs

 Asymmetry of shoulders (one shoulder seems

higher than the other)
 Asymmetry of hips
 Asymmetric scapulae and the chest wall.
 Shortened trunk
 Malalignment of trunk and pelvis
 Unequal leg lengths
 Patients may initially report fatigue in the lumbar
region after prolonged sitting or standing.
 Muscular backaches in areas of strain (eg, in the lumbosacral angle).
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Diagnosis

1- Taking history: history of scoliosis in the family, the age at which the curve began,
the curve's location and severity of the curve. Most spine curves in children with
scoliosis will remain small and need only to be watched by an orthopedist for any
sign of progression.

2- Physical examination: sings of scoliosis, observe back while child stand with his
arms at your sides. They’ll check for spine curvature and whether his shoulders and
waist area are symmetrical.

3- Investigations

 X-ray of the spine

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 X-ray examination should include
standing anteroposterior and lateral
views of the spine. Most curves are
convex to the right in the thoracic
area and to the left in the lumbar
area, so that the right shoulder is
higher than the left.

The amount of curvature is quantified in

degrees based on x-ray findings (the
Cobb method). In this method, two lines
are drawn on a posterior-anterior x-ray
of the spine, one extending from the top of the most tilted upper vertebra and the
other from the bottom of the most tilted lower vertebra. The angle formed by these
lines is the Cobb angle.

 MRI scan: This test uses radio and magnetic waves to get a detailed picture of
bones and the tissue surrounding them.

 CT scan: During this test, X-rays are taken at a variety of angles to get a 3-D
picture of the body.

Prognosis

The greater the curve, the greater the likelihood that it will progress after the
skeleton matures. Curves > 10° are considered significant. Prognosis depends on site
and severity of the curve and age at symptom onset. Significant intervention is
required in < 10% of patients.

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Treatment

 Physical therapy and bracing: Moderate curves (20 to 40°)

are treated conservatively (eg, physical therapy and bracing)
to prevent further deformity.

- Worn 16-23 hrs /day with time out for hygiene and skin
care
- usually recommend that children wear their braces until
they reach adolescence and are no longer growing.
- Brace must be adjusted with growth
- Observe for skin breakdown
- Should wear a light cotton tee shirt under the brace

 Surgery: Severe curves (> 40°) may be ameliorated surgically (eg, spinal fusion
with rod placement).

Spinal fusion is the standard scoliosis surgery. In this procedure, the doctor
fuses your vertebrae together using a bone graft, rods, and screws. The bone
graft consists of bone or a material like it.

The rods keep your spine in a straight position, and the screws hold them in
place. Eventually, the bone graft and vertebrae fuse into a single bone. Rods
can be adjusted in children as they grow.

 Scoliosis and its treatment often interfere with an adolescent’s self-image

and self-esteem. Counseling or psychotherapy may be needed.

Nursing Management

Nurses play an important role in the management of a child with scoliosis, especially
for the postoperative care.

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Nursing Assessment

The child with scoliosis must be reassessed every 4 to 6 months.

 Degree of curvature. Document the degree of curvature and related

impairments.
 Provide privacy. Provide privacy and protect the child’s modesty.
 Assess emotional status. Be sensitive to the emotional state of the child; the
family caregivers also may be upset but trying to hide it for the child’s sake.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

 Impaired physical mobility related to restricted movement.

 Risk for injury related to decreased mobility.
 Risk for impaired skin integrity related to irritation of brace.
 Risk for disturbed body image related to wearing a brace continuously.
 Risk for noncompliance related to long-term treatment.

Nursing Care Planning and Goals

Major nursing care planning goals for the child with scoliosis include:

 Minimizing the disruption of activities.

 Preventing injury.
 Maintaining skin integrity and self-image.
 Complying with long-term care.

Nursing Interventions

Nursing interventions appropriate for the child with scoliosis are:

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  Promote mobility. Prescribed exercises must be practiced and performed as
directed; this can help to minimize the risks of immobility and promote self-
esteem.
 Prevent injury. Evaluate the child’s environment after the brace has been
applied and take precautions to prevent injury; help the child practice moving
about safely; advise the family caregiver to contact school personnel to
ensure that the child has comfortable, supportive seating at school.
 Prevent skin irritation. Check the child regularly to confirm proper fit of
brace; observe for any areas of rubbing, discomfort, or skin irritation and
adjust the brace as necessary; skin under the pads should be massaged daily;
and daily bathing is essential.
 Promote positive body image. The child should be involved in all aspects of
care planning; it is important for the child to have an opportunity to talk
about his or her feelings; help the child select clothing that blends with
current styles but is loose enough to hide the brace.
 Promote compliance with therapy. The child must wear the brace for years
until spinal growth is completed; during this period, the caregivers and the
child need emotional support from healthcare personnel; to encourage
compliance, teach them about possible complications of spinal instability and
possible further deformity if correction is unsuccessful.

Evaluation

Goals are met as evidenced by:

 Minimized disruption of activities.

 Prevention of injury.
 Maintained skin integrity and self-image.
 Compliance with long-term care.

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 ENDOCRINE DISORDERS
Outlines:

o Objectives.
o Introduction.
o Overview of endocrine system.
o Concept of endocrine disorders.
o Causes of endocrine disorders.
o Common pediatric endocrine disorders.
- Hypothyroidism.
- Diabetes mellitus.
o Nursing management of children with endocrine disorders.

Objectives:

At the end of this lecture each student will be able to :

1. Give an overview of the endocrine system .

2. Clarify concept of endocrine disorders.
3. Interpret the causes of endocrine disorders.
4. Describe common pediatric endocrine disorders.
5. Clarify nursing management of children with endocrine disorders.

Introduction:

The endocrine system is important to the proper development and growth of children.
The primary organs produce hormones, chemicals that control different processes

348
 within the body, including growth, blood sugar regulation. When any of these glands
release too much or too little hormone, disorder can occur such as hypothyroidism,
diabetes mellitus and common pediatric endocrine emergences such as diabetic
ketoacidosis. Endocrine emergencies represent a group of potentially life-threatening
conditionsthat are resulting in delays in both diagnosis and treatment, and associated
high mortality rates. These conditions include diabetic keto acidosis, so the nurse plays
an important role in dealing with children having endocrine disorders.

An overview of Endocrine System:

The endocrine system is a system of glands, each of which secretes a type of hormone
directly into the bloodstream to regulate the body function. Hormones regulate various
human functions, including metabolism, growth and development function.

The main endocrine glands in the body are:

 Pineal gland
 Pituitary gland ―called the master gland‖.
 Thyroid gland.
 Parathyroid gland.
 Thymus gland(located behind sternum and between lungs, is only active until puberty.
After puberty, the thymus starts to slowly shrink and become replaced by fat.
 Islets of Langerhans( pancreas).
 Adrenal gland .
 Sex glands.

349
Endocrine Glands and Their Associated Hormones

Endocrine Associated
Gland Hormones Effect

growth hormone promotes growth of body tissues

prolactin promotes milk production

thyroid-stimulating
Pituitary stimulates thyroid hormone release
hormone
(anterior)
adrenocorticotropic stimulates hormone release by adrenal
hormone cortex

follicle-stimulating stimulates gamete production(sperm and

351
Endocrine Glands and Their Associated Hormones

Endocrine Associated
Gland Hormones Effect

hormone egg)

stimulates androgen production by gonads

luteinizing in males; stimulates ovulation and
hormone production of estrogen and progesterone in
females

antidiuretic
stimulates water reabsorption by kidneys
Pituitary hormone

(posterior) stimulates uterine contractions during

oxytocin
childbirth

stimulate metabolism,also play a key role in

thyroxine, bone growth and the development of the

Thyroid triiodothyronine brain and nervous system in children.

calcitonin reduces blood Ca2+ levels

parathyroid
Parathyroid increases blood Ca2+ levels
hormone

it stimulates the development of disease-

Thymus gland
Thymosin fighting T cells.

aldosterone increases blood Na+ levels

Adrenal (cortex)
cortisol, increase blood-glucose levels

351
 Endocrine Glands and Their Associated Hormones

Endocrine Associated
Gland Hormones Effect

corticosterone,
cortisone

Adrenal epinephrine,
stimulate fight-or-flight response
(medulla) norepinephrine

insulin reduces blood-glucose levels

Pancreas
glucagon increases blood-glucose levels

Concept of endocrinedisorders

Endocrine disorders are disturbance in the function of endocrine gland, which often quite ,
complex, involving a mixed picture of hyposecretion and hypersecretion. For example,
most forms of hyperthyroidism are associated with an excess of thyroid hormone and a low
level of thyroid stimulating hormone.

So endocrine disorders may be subdivided into three groups:

 Endocrine gland hyposecretion (leading to hormone deficiency)
 Endocrine gland hypersecretion (leading to hormone excess)
 Tumors (benign or malignant) of endocrine glands.

Causes of endocrine disorders

 Failure of a gland to stimulate another gland torelease hormones (for example, a
problem with the hypothalamus can disrupt hormone production in the pituitary gland).
 A genetic disorder, such as congenital hypothyroidism or multiple endocrine neoplasia
"are rare, inherited disorders in which several endocrine glands develop noncancerous
(benign) or cancerous (malignant)
352
 Infection.
 Tumor of an endocrine gland.
 Injury to an endocrine gland

Common pediatric endocrine disorders

Hypothyroidism

Is a deficient production of thyroid hormone, which result in generalized slowing down

metabolic process and slowing growth and development with serious permanent
consequences including mental retardation.

Incidence:

 According to National Center Biotechnology Information (NCBI),(2017): The

general Incidence of congenital hypothyroidism is a bout (1\4000) in Egypt per
year.
 Is the commonest endocrinal disorder in children.
 Congenital hypothyroidism usually presents in neonatal period or early infancy.
 Acquired hypothyroidism is mostly seen in school age children.
 Screening program is currently available in Egypt.
Etiology and predisposing factors:

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 ftoioyos osev v oy i os ot f of l tvf ns ofv
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 Autoimmune vfito ve
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353
myidiopy efpfHaf ce ulacf lacinilC:

In neonatal period:

 Prolonged physiological jaundice(more than 2-3 weeks).

 Feeding difficulties and poor activity
 Large anterior fontanelle, with delayed closure.
 Cold mottled skin.
 Constipation.

In infancy period:

-Delayed motor development (delayed head support, delayed

sitting).

 Delayed mental development (delayed smiling, laughing,

recognition of mother).
 Coarse features (large head, coarse hair with low anterior
hair line, swollen eye lids, depressed nasal bridge,thick protruded tongue).

In childhood period:

 Slowed growth rate

 Puffy face
 Swollen hands and feet
 Poor muscle tone
 Constipation
 Fatigue
 Dry, itchy scalp
 Dry, coarse skin
 Heavy menstruation in girls
 Mood swings
 Weight gain
354
  Hoarse cry or voice
 Enlarged thyroid gland (goiter)

ulacf lacinilC fipsdclil ce:

1-Serum level of thyroid hormones (T3-T4)

 T4 level below 6mcg/dl is diagnostic

 Normal level of T4 is 9-18 mcg/dl in neonate

7-15 mcg/dl in infant and children

2-Serum level of thyroid stimulating hormones (TSH): High level above 50 or

even 100 micro unit/ml usually occur in primary hypothyroidism. Normal level is
below 10 mcg/ml. in secondary and tertiary hypothyroidism, the level of TSH is low.

Prevention
Prevention of hypothyroidism can be achieved with the following:
 Increase in iodine intake. Iodine intake is the foremost prevention strategy in
hypothyroidism.
 Early detection and prompt treatment of hypothyroidism.

Complications
Hypothyroidism can be a life-threatening disease if left unchecked.
Myxedema coma. This is the decompensated state of severe hypothyroidism in which
the patient is hypothermic and unconscious.

Medical Management
The primary objective in the management of hypothyroidism is to restore a normal
metabolic state by replacing the missing hormone.
 Pharmacologic therapy. Synthetic levothyroxine is the preferred preparation for
treating hypothyroidism and suppressing nontoxic goiters.

355
  Supportive therapy. Oxygen saturation levels should be
monitored; fluids should be administered cautiously; application of external
heat must be avoided, and oral thyroid hormone therapy should be continued.

Nursing Management
Nursing care for a patient with hypothyroidism includes the following:
Nursing Assessment
Assessment of the patient with hypothyroidism should include:
 Assessment of the thyroid position.
 Assess thyroid gland for firmness (Hashimoto’s) or tenderness (thyroiditis).
Diagnosis
Based on the assessment data, the nursing diagnoses appropriate for a patient with
hypothyroidism are:
 Activity intolerance related to fatigue and depressed cognitive process.
 Risk for imbalanced body temperature related to cold intolerance.
 Constipation related to depressed gastrointestinal function.
 Ineffective breathing pattern related to depressed ventilation.
 Disturbed thought processes related to depressed metabolism and altered
cardiovascular and respiratory status.
Planning & Goals
To achieve a successful nursing care plan, the following goals should be realized:
 Increase in participation in activities.
 Increase in independence.
 Maintenance of normal body temperature.
 Return of normal bowel function.
 Improve respiratory status.
 Maintenance of normal breathing pattern.
 Improve thought processes.

356
Nursing Interventions
Nursing interventions for a patient with hypothyroidism include the following:
 Promote rest. Space activities to promote rest and exercise as tolerated.
 Protect against coldness. Provide extra layer of clothing or extra blanket.
 Mind the temperature. Monitor patient’s body temperature.
 Increase fluid intake. Encourage increased fluid intake within the limits of
fluid restriction.
 Provide foods high in fiber.
 Manage respiratory symptoms. Monitor respiratory depth, rate, pattern,
pulse oximetry, and ABG.
 Pulmonary exercises. Encourage deep breathing, coughing, and use of
incentive spirometry.
 Orient to present surroundings. Orient patient to time, place, date, and
events around him or her.
Discharge and Home Care Guidelines
At the completion of the home care instruction, the patient or caregiver will be able to:
 Medication compliance. State that compliance to medical regimen is life-
long.
 Cold intolerance. State the need to avoid extreme cold temperature until
condition is stable.
 Follow-up visits. State the importance of regular follow-up visits with health
care provider.
 Weight reduction. Identify strategies for weight reduction and prevention of
constipation such as high-fiber, low-calorie intake and adequate fluid intake.

357
 Diabetes mellitus

Diabetes mellitus (DM) is an important endocrine disorder that presents commonly

in children and adolescents. There are two types of diabetes mellitus: type 1 and type 2.
Type 1 DM is one of the most common chronic diseases in children and is characterized
by insulin deficiency as a result of autoimmune destruction of pancreatic beta islet cells;
whereas type 2 DM is the presence of high blood glucose with insulin resistance and
relative insulin deficiency. Diabetes mellitus is a chronic condition that requires long-
term follow-up and adequate patient (and parent) education to maintain good glycemic
control to prevent long-term complications.Syndrome characterized by short-term
complications include (Hyperglycemia, Hypoglycemia, and Diabetic ketoacidosis).
While long-term complications include vascular complications .

Concept of diabetes mellitus:

 Diabetes mellitus is a chronic metabolic disorder, caused by deficiency of insulin

secretion, insulin action or both, which characterized by disturbances of
carbohydrate, fat and protein metabolism.

Incidence of Diabetes Mellitus:

 According to ( World Health Organization, 2017): the incidence of diabetes in
new born is 0.2% , infant is 0.3% and toddlers is 0.21% in Egypt.
 Approximately 1.4 million American children are diagnosed with diabetes every
year. Type1 diabetes remained the 7th leading cause of death in the United States in
2010 (American Diabetes Association, 2015). While in Egypt, it accounts for
about 8/100 000 children per year (El- Ziny et al., 2014).

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 Pathophysiology of diabetes mellitus:

Types of Pediatric Diabetes Mellitus:

According to(American Diabetes Association, 2014).There are three major types of

diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.
1) Type 1 Diabetes , insulin-dependent diabetes mellitus (IDDM) or
Juvenile diabetes
 Type 1 diabetes is a chronic autoimmune disorder that precipitates in
genetically susceptible individuals by environmental factors.
 It caused by an absolute deficiency of insulin which is produced by the beta
cells of the islets of Langerhans located in the pancreas.
 The exact cause of Type I Diabetes is actually unknown, but there are
predisposing factors that contribute to the onset of diabetes .

Predisposing factorsfor type I:

 Genetic predisposition if parent has type I

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  Dietary factors :No specific diet cause diabetes ,but exposure to cow’s milk
proteins or bovine serum albumin at age less than 3 months ,lead to the
development of antibodies that attack the beta cells of the pancreas .
 Viral infections such as mumps and congenital rubella.
 Autoimmune disorder: The immune system attacks itself, as result of
exposure to some disorder as thyroid disorder.

2)Type 2 Diabetes or non insulin-dependent diabetes mellitus

(NIDDM):
 It results from insulin resistance, in which the cell of the body fails to use
insulin properly. It also known as adult-onset diabetes.
 May respond to life style change and oral medication.

3) Gestational diabetes Mellitus (GDM):

Has been defined as any degree of glucose intolerance with onset or first recognition
during pregnancy and usually develops in the third trimester and typically disappears
after the baby is born. It may precede development of type 2 DM. Also, increase risk
of cesarean delivery, perinatal death, and neonatal complications.

Clinical manifestations of Diabetes Mellitus:

 Polyuria.
 Polydipsia.
 Polyphagia.
 WT loss.
 Blurred vision.
 Coma in neglected cases.
 Dry mouth or throat
 Feeling tired or weak.
 Muscle cramps.
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 Slow growth.
 Behavior problem as restless and apathy.
 Stomach aches
 Nausea and vomiting

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Diagnosis of Diabetes Mellitus:

a) History taking:Family history (risk increases if a parent or sibling has diabetes)

&history of symptoms
b) Physical examination: The criteria for diagnosis of diabetes mellitus in children and
adolescents
c) laboratory investigation which include:confirmed the diagnosis of diabetes through
perform
 Random blood glucose level ≥ 200 mg/dL.
 Fasting blood glucose level > 126 mg/dl.

 Post prandial(2hr. after meal) ≥ 200mg/dl.

 Urine analysis: Presence of ketone and glucose in urine.

 Serum electrolyte (Na, K, Ca): Disturbance of level below normal.

 Arterial Blood Gases (ABG):PH, O2 saturationand bicarbonate (Co2).
 ECG: Inverted of ST segment which indicate decrease potassium level.

Treatment of Diabetes Mellitus:

 A therapeutic regimen is a plan for treatment of diabetes mellitus. This can involve
participation between children, family and care providers in treatment.

 Treatment depends on many factors, such as the type of diabetes and the ability of
pancreas to manufacture insulin and combination of the following:

 Continuous glucose monitoring (CGM).

 Insulin therapy for type 1diabetes and oralmedications in type II.
 Regular physical Exercise.
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  Diet Regimen
 Continuous glucose monitoring (CGM):

Monitoring of glycemic control includes daily monitoring of glucose at home as well as

periodic monitoring of overall glycaemia, to help in reducing the risk of hypoglycemia,
hyperglycemia, Diabetic Ketoacidosis (DKA), and chronic complications of vascular
diseases.
 Insulin therapy:

Insulin is a hormone made by the pancreas thatcontrols the level of the glucose in the
blood, permits cells to use glucose for energy. Cells cannot utilize glucose without
insulin.
Aim of the insulin therapy are
1. Save life.
2. Alleviate symptoms.
3. Maintain blood glucose as near to normal.
4. Minimize long term complications.

Types of Insulin:
 Rapid-acting: begin to work within 5 to 15 minutes and are active for 3 to 4 hours.
 Short-acting: starts working within 30 minutes and is active about 5 to 8 hours.
 Intermediate-acting: starts working in 1 to 3 hours and is active 16 to 24 hours.
 Long-acting:starts working in 4 to 6 hours, and is active well beyond 32 hours.
Modes of administration of insulin:

 Insulin syringe:subcutaneousinjections by single-usesyringeswithneedles

 insulin penswith needles:preloaded with insulin; ―dial‖ the dose.
 Insulin pump:Computerized device, worn around the waist.Continuous ―basal‖
infusion. At mealtime, user programs to deliver ―bolus‖ infusion that correlates

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 with amount of CHOs ingested. Allows tight control and greater flexibility with
meals and activity
New Insulin Preparation:

 Nasal and inhaled insulin was not successful because of variable nasal absorption.
 Oral insulin preparations are under trials.

Injection sites:Insulin is injected into the subcutaneous tissue.Rotating injection

sites.There are several different sites where insulin can be injected, includingabdomen,
upper arms, thighs, or hips.
 Regular Physical Exercise:
 Exercise is an important aspect of diabetes management;it lowers blood glucose
and increases the speed of insulin absorption by the body, so children should be
encouraged to exercise regularly.
 In general, provide extra food for extra exercise. Children need about 10 to 15
grams of carbohydrate for every 30 minutes of activity outside the usual. If
possible, check blood glucose levelsbefore and after the activity.

 Diet Regimen:
 Diet is a major component of treatment for every child with diabetes, formulation
of a diabetic diet depends on the child's sex, age, height and weight, in addition
activity level, state of health and former diet allowance (calories, percentage of
carbohydrates, fats and proteins are prescribed).
 Special considerations for type 1 and type 2 diabetes:
- carbohydrates 45-50% daily energy intake
- protein 30-35%
- Fat: 10- 15 %
-

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 Complications of Diabetes:
• Acute:
 Hypoglycemia.
 Hyperglycemia.
 DKA
• Late-onset:
 Retinopathy
 Neuropathy
 Nephropathy
 Ischemic heart disease & stroke
Hyperglycemia

Symptoms of Hyperglycemia:
Symptoms include the following:
 Frequent urination.  Itching
 Increased thirst.  Blurred vision
 Hunger.  Nausea
 Dry mouth.  Drowsiness.

Treatment of Hyperglycemia:
 Monitoring glucose level.
 Raise the insulin dose.
 Recommend dietary changes.
 Recommend more exercise.

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 Hypoglycemia

Defined as a fall of the blood glucose level <65mg/dL that exposes a patient to
potential harm and there can be no single numerical definition of hypoglycemia for all
patients and situations.

Signs and Symptoms:

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  Shakiness
 Nervousness or anxiety
 Sweating or diaphoresis,chills and clamminess
 Irritability or impatience, Anger.
 Confusion, including delirium
 Rapid/fast heartbeat
 Lightheadedness or dizziness
 Hunger nauseaand vomiting
 Blurred/impaired vision
 Tingling or numbness in the lips or tongue
 Headaches,Weakness or fatigue

Treatment of hypoglycemia:
1- Consume 15-20 grams of glucose or simple carbohydrates as:
 Glucose tablets (follow package instructions)
 1/2 cup of juice
 1 tablespoon sugar, honey, or corn syrup
2- Recheck blood glucose level after 15 minutes If hypoglycemia continues,
repeat.
3- Once blood glucose returns to normal, eat a small snack if the next planned
meal or snack is more than an hour or two away to consume) .

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Nursing Management of Children with Diabetes
Mellitus:

Assessment:
 Assessment history of symptoms related to the diagnosis of
diabetes.
 Physical assessment such as: polyuria, polydipsia, polyphagia,
skin dryness, blurred vision, weight loss, Blood glucose levels,
ketonuria and vomiting.
 Assess the body mass index and visual acuity of the child.
 Assess the child blood pressure, respiration, temperature and pulse
 Assess emotional and psychological status of the child by
observing general demeanor (e.g., withdrawn, anxious) and body
language (e.g., avoids eye contact).
 Assess Laboratory examinations as blood glucose level, micro
albuminuria test, serum creatinine level, urine test, and ECG must
be requested and performed.
Nursing diagnosis:
 High blood glucose level related to Lack of adherence to diabetes
management, Lack of acceptance of diagnosis and Stress.
 Insufficient Nutrition less than body requirements related to insulin
deficiency and decreased oral intake
 Lack of knowledge about diabetes and its management
 Risk for fluid volume deficit related to Osmotic diuresis (from
hyperglycemia), Excessive gastric losses.
Planning and goals:
 Optimal control of blood glucose levels.

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  Maintain well balanced diet.
 Parents and children demonstrate knowledge about diabetes and
self- care measures.
 Demonstrate adequate hydration as evidenced by stable vital signs
and good skin turgor & capillary refill
Nursing interventions

Optimal control of blood glucose levels:

 Monitoring blood glucose level before meals and at bedtime.
 Instruct the parents on the proper preparation and administration of
insulin.
 Educate the patient about the importance of following a prescribed
meal plan.
 Discuss the importance of balance exercise with food intake.

Maintain well balanced diet:

 Weight daily or as indicated.
 Identify food preferences, including ethnic/cultural needs.
 Provide liquids containing nutrients and electrolytes as soon as
patient can tolerate oral fluids.
 Provide diet of approximately carbohydrates 45-50% daily energy
intake, protein 30-35%, Fat: 10- 15 %in designated number of
meals/snacks.

Demonstrate knowledge about diabetes and self- care measures:

 Assess ability to learn or perform desired health-related care.
 Assess motivation and willingness of patient and family to learn.
 Assess for family patterns, economic issues, and cultural patterns
that influence compliance with a given medical regimen.

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  Help client to choose healthy lifestyle and to have appropriate
diagnostic screening tests.
 The child\family is taught survival skills, including treatment
modalities (diet, insulin administration, monitoring of blood
glucose, and, for type 1 diabetes, monitoring of urine ketones)
 recognition treatment and prevention of acute complications.
 Emphasize the importance of follow-up to the outpatient clinic,
dentist, optician and general practitioner.

Demonstrate adequate hydration:

 Intake and output are measured
 IV fluids and electrolytes are administered as prescribed
 Vital signs are monitored for signs of dehydration (tachycardia,
hypotension) along with assessment of breath sounds, level of
consciousness, presence of edema.
 Laboratory values of serum electrolytes (especially sodium and
potassium) are monitored.

Evaluation:
 The effectiveness of nursing intervention is determined by
continual reassessment and evaluation of care.
 Evaluate the parent and child’s knowledge and understand of
diabetes management, self-management skills, including the ability
to perform procedures for blood glucose monitoring and maintain
well balanced diet.

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References
Bowden, V. and Greenberg, C. (2016): Pediatric Nursing Procedures,
4th ed., Wolters Kluwer, Chinn.

Correia, C. (2017): Pediatric Nursing Procedure Principles and Practice,

Shree Maitrey printech pvt. Ltd, Noida, India.

- Datta,P., (2007): Pediatric Nursing, Chapter 19, P, 361 : 363.

- Beevi, A., (2009): Textbook of Pediatric Nursing, El Sevier, P; 306.

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