PEDIATRICS IN NURSING

ESSENTIAL NEWBORN CARE

Simple, evidence-based intervention that may help in ensuring the survival of all newborns and the mother.
Four Time-Bound Interventions:
1. Immediate and Thorough Drying – done 1st 30 seconds of delivery (PRIORITY)
a. Prevent Hypothermia also Stimulating the closure of ductus arteriosus, ductus venosus, foramen ovale
2. Early Skin-to-Skin Contact – done 1st 30 seconds after delivery
3. Properly timed cord Clamping and Cutting – done between 1 to 3 minutes
a. Prevent Anemia to the Newborn
4. Non-separation of the newborn to the mother and Breastfeeding Initiation – within 90 minutes
a. Prevent Hypoglycemia to the Newborn
IMMEDIATE AND THOROUGH DRYING AND EARLY SKIN-TO-SKIN CONTACT
FROM BIRTH TO 30 seconds
a. Call out time birth and sex of the baby
a. also assessing neonatal hearing or Moro Reflex
b. Deliver the baby onto the dry cloth draped over the mother’s abdomen or arms
c. START BY DRYING baby within 5 seconds after birth
d. CHECK BREATHING while drying
a. No suctioning if baby is crying because it will promote infection. SUCTIONING IS UNNECCESSARY IF BABY IS CRYING
e. Remove the wet cloth and to start SKIN-TO-SKIN CONTACT – abdomen to abdomen
a. Note: Spread Vernix Caseosa because it is responsible for thermoregulation
f. COVER THE BABY with dry cloth and head with bonnet
a. Room Temperature: 25 to 28 degrees Celsius
g. NO ROUTING SUCTIONING
h. Is the baby gasping or not breathing = clamp and cut the cord immediately and start ventilation
a. If suctioning of the baby: Mouth first, then nose.
b. Newborns are NOSE BREAHTER
i. IF THE BABY IS BREATHING
a. Continue skin-to-skin contact. Turn the baby’s head to one side.
b. Healthy skin bacteria from the mother are transferred onto the newborn’s skin during skin-to-skin contact
c. Placing the newborn on mother’s abdomen or chest allows the newborn to crawl up
d. Skin-to-skin contact also improves breastfeeding initiation
e. INJECT OXYTOCIN 10 MINUTES IM TO THE MOTHER before placental delivery or after skin-to-skin contact (within 1
minute of baby’s birth).
j. NOTES:
a. Low Birth Weight (Less than 2500g) who do not have complication should be maintained in skin-to-skin contact
b. NOTE: Do not suction unless the mouth and nose are blocked. Do not suction Meconium unless the baby is not vigorous
c. If the baby is breathing normally or crying, avoid manipulation like suctioning that may cause trauma and infection.
d. Do not separate the baby from as long as the baby is well.
e. Do not remove Vernix Caseosa earlier than 6 hours
i. Temperature of Newborn will stabilize after 6 to 8 hours
ii. WE DO NOT BATH THE BABY AFTER BIRTH BECAUSE IT WILL HINDER ROOTING REFLEX
f. Place the identification band on the baby’s ankle.
g. If there is another baby, get help
PROPERLY TIMED CORD CLAMPING AND CUTTING
a. Remove the soiled set of gloves
b. Clamp/cut the cord after pulsation stops
a. Between 1 to 3 minutes to prevent Anemia to the Newborn because it increases the birth storage of the Iron
c. NO CORD MILKING
a. To prevent Intra Ventricular Hemorrhage (IVH)
b. If we milk (towards the baby) the cord, the tiny blood vessels to rupture because of the pressure that
d. Do not put anything on the cord (beneficial)
a. It keeps the cord moist; moisture will prevent the invade of bacteria
e. Delayed Cord Clamping (beneficial)
f. No cord bandaging
g. At Home, do not touch the cord unnecessarily
h. If the cord is soiled, wash with mild soap and water
i. If the umbilicus is red and draining pus, report, because it may indicate local infection.
j. Cord falls off within 7 to 10 days after delivery
a. Allow to baby to bath – cleanest to dirties
NONSEPARATION OF THE NEWBORN TO THE MOTHER AND BREASTFEEDING INITIATION
AT LEAST 60 MINUTES, unless in respiratory distress or with maternal emergency
Encourage breastfeeding WHEN BABY SHOWS FEEDING CUES:
1. Rooting
2. Opening of the mouth
3. Tonguing
4. Licking
NOTES: Wet Nursing – feeding the newborn from the other breast.
Normal Newborn RR: 30 – 60
Use cup when feeding the baby to prevent nipple confusion
SUGGEST TO THE MOTHER TO NUDGE THE BABY TOWARDS THE BREAST
 MAKE SURE:
o Baby’s neck is not flexed nor twisted.
o Baby is facing the breast.
o Baby’s nose is opposite her nipple.
o The chin is touching the breast.
o Baby’s body is close to mother’s body.
o Support the whole body, not just the neck and shoulder.
o Wait until her baby’s mouth is opened wide.
o Move the baby onto her breast, aiming the lower lip well below the nipple.

SIGNS OF GOOD ATTACHMENT

 Mouth opened wide.
 Lower lip turned outwards.
 Baby’s chin is touching the breast.
 Slow and deep sucking with some pauses.
o Smacking sounds is incorrect latch-on will lead to nipple discomfort.

NOTES:
 Do not touch the baby unless there is a medical indication
 Do not give sugar water, formula and other prelacteals
 Do not give bottles and pacifiers – to prevent nipple confusion
 Do not throw away colostrum – colostrum is the first perfect food. (IgE if pregnant, IgA if lactating)
o Colostrum is until 3 to 4 days post-partum
 Mother’s Breast should be the FIRST AND ONLY SOURCE OF FEED to ensure successful breastfeeding
 What is the most important outcome of Unang Yakap? Breastfeeding Promotion
 3 E’s of Breastfeeding
o E – Early
o E – Exclusive - Breastmilk is 90% water, enough to prevent dehydration of the baby.
 Exceptions: Medicines, Vitamins, Supplements
o E – Extended – up to 2 years or beyond.

Determining the APGAR SCORE

 At 1 Minute, to determine the need to resuscitate the Newborn
 At 5 minutes, to check for the adjustments to extrauterine life and to check for prognosis, if resuscitation made is effective.
 Proponent of APGAR, Verginia Apgar

0 1 2
APPEARANCE Absent Acrocyanosis Totally pink
(color) First 24 – 48 hours
PULSE/HR Absent Less than 100 More than 100
GRIMACE/REFLEX No Response Minimal, Facial Grimace Strong Cry, Sneezing,
IRRITABILITY Coughing
ACTIVITY/ MUSCLE TONE Limp and Floppy Some Flexion Full Flexion
 RESPIRATORY EFFORT Absent or Apnea Slow and Irregular Cry Vigorous Cry
 NOTE:
o Shallow, initiated by abdomen, 30 – 60 cpm, irregular
o Most important is PULSE/HR
o Second Most Important is RESPIRATORY EFFORT
o Least Important is APPEARANCE due to Acrocyanosis
 Acrocyanosis is pink body and blue extremities that occurs 24 to 48 hours,
 85% of Newborn due to sluggish peripheral circulation
 Do not take pulse rate in extremities due to acrocyanosis
 Management: Avoid exposure to cold environment
o Occasional Sneezing is good sign of respiration
o Full flexion = flexion of all extremities
o Some Flexion = Upper extremities are flexed and lower extremities if flop
o Full Term – Full Flexion
o Preterm = Some Flexion
 Scoring
o 7 – 10 – Newborn is doing well (Routine Newborn care)
o 4 – 6 – Moderately depressed (Needs special intervention)
o 0 – 3 – Severely depressed (Resuscitate)

DO EYE CARE BEFORE 1 HOUR

When newborn has located the breast
1. Eye Prophylaxis (Erythromycin)
2. To prevent Ophthalmia Neonatorum
a. Causes of Ophthalmia Neonatorum: Chlamydia and Gonorrhea
3. Inner to Outer (Manner) Canthus – Do not wipe the excess
FROM 90 MINUTES
 After the newborn has detached from the breast
1. Examine the baby
2. Weigh the baby and record
3. Provide preventive measure
a. Vitamin K
i. IM – Vastus Lateralis
ii. To prevent bleeding
b. Hepatitis B Vaccine
i. IM – Vastus Lateralis
c. BCG Vaccine
i. ID
 Monitor the baby every 15 minutes
 Postponed bathing until after more than 24 hours of age (do not discharge baby and mother within 24 hours)
 Provide routine postnatal care
 Reexamine the baby before discharge
o Look For Danger Signs:
 Stopped feeding well
 Convulsions
 Fast breathing – more than 60 breaths per minute
 Severe chest in-drawing
 No spontaneous movement
 High and Low body temperature
 Do not discharge before 24 hours after birth
NON-IMMEDIATE INTERVENTION
1. Bathing
2. Removal of Vernix Caseosa
3. Anthropometric Measurements
4. Newborn Screening
5. Giving Medications (vaccines and eye prophylaxis)
UNNECESSARY INTERVENTION
1. Chest Compression 5. Cord Milking
2. Haning 6. Cord Bandaging
3. Turning Upside-Down 7. Putting anything medications onto cord
4. Slapping 8. Foot printing
 9. Routine suctioning 11. Wristband
10. Routine separation 12.
MECHANISM OF HEAT LOSS
1. Evaporation – Fluid to Gas (drying the baby)
2. Convection – Air Currents
3. Conduction – Direct Contact to cold object
4. Radiation – Indirect Contact to cold solid object
COMPLICATIONS OF COLD STRESS
1. Acidosis
2. Respiratory Distress
3. Hypoglycemia
NOTE: Exposure to the Newborn to Cold Stress will lead to Brown Fat Metabolism (which is lipolysis) and lead to heat production.
Lipolysis will increase the utilization of Glucose leading to Hypoglycemia.
Lipolysis also increases the Oxygen utilization leading to Respiratory Distress leading to ACIDOSIS.
Lipolysis is the by product of ketones also contribute to ACIDOSIS
*Preterm baby has difficulty producing body heat because they lack subcutaneous fats deposition wherein subcutaneous fats are heat
insulators. (Need to maintain skin-to-skin contact within 24 hours or Incubators)
ROOMING-IN
 The practice of placing the newborn and the mother in the same room right after delivery up to discharge to FACILITATE
BONDING
 Infants delivered by NSD shall be put on the mother’s breast and forthwith roomed in with 30 minutes (well infatns regardless AOG
and Infants with Low Birth Weight (LBW) BUT WHO CAN SUCK)
 Infants delivered via CS shall be roomed in within 3 – 4 hours
CONDITION DO NOT PERMIT ROOMING-IN
 Psychotic Mother
 Mothers needing Intensive care
 Newborn who needs Intensive Care
 Infants shall be fed with expressed breastmilk through cup and wet nursing.
 Breastfeeding TSEK
o T – Tama (Right)
o S – Sapat
o EK – Ekslosibo (Exclusive)
 Breastfeeding Awareness Months is every August
 Provision of Kangaroo Mother Care:
o Continuous skin-to-skin contact
o Exclusive breastfeeding for the first 6 months
o Early discharge from the hospital. Discharge no earlier than 24 hours
o Close follow up at the health facility for uncomplicated delivery.
 Newborn must be check:
 Within 24 hours
 3 days
 Postnatal check-up within 6 weeks including immunizations
 Call the Healthcare Provider If:
o Cyanosis
o Jaundice
 Jaundice within 24 hours is Pathologic due to destruction of RBC of the fetus
 Jaundice within 3 – 6 days is Physiologic due to Immature Liver
o Temperature above 38 degrees Celsius or below 36.5
o Vomiting
 Capacity of the Stomach – Age in Months + 2 ounces (30 mL per ounce)
o Refusal of two feedings in a row
 Best schedule of breastfeeding: According to baby’s demand
o Diarrhea (Normal Frequency: 1 – 3 daily)
 Stools:
 Meconium Stools – Day 1 (blackish green, thick)
 Transitional Stools – Day 2 -3 (green and loose)
  Breastfed Stools – Day 4 and above (light yellow, soft, and sweet smelling because of the presence of
lactose)
 NOTE: Formula fed babies has formed and smelly stools because of the Fortification of Iron
o No bowel movements for more than 24 hours
 May be due to Imperforate Anus, Hirschsprung Disease, Cystic Fibrosis
 Compensatory Mechanism of Infants who have Imperforate Anus is Fistula (abnormal connection)
 Boy who has green tinged urine has Fistula
 Girl who has green tinged in vagina has Fistula
 Hirschsprung Disease – absent of Ganglion (Ganglion is responsible for Peristalsis)
 12 months to 18 months – Bowel Resection
 Surgery: Temporary Colostomy (1st year)
 After surgery the peristalsis should be present
 Cystic Fibrosis – absence of pancreatic enzyme
 Pancreatic Enzymes is responsible for softening of meconium
 The absence of Pancreatic Enzymes will make the meconium hardened (Meconium Ileus)
 Enema will help to soften the meconium
 If enema not work, surgery.
o No urination for 12 hours
 Normal: 2 days = 2-6 times
 After 2 days: 6 – 8 times
o Signs of infection in the eyes, umbilical cord or circumcision
o Pustules, blisters or rashes on the skin
o Difficulty in waking baby common at preterm
o Any unusual changes in the infant’s behavior or appearance
 Shrill Cry – High-pitched cry
BREASTFEEDING

LACTOGENESIS LET-DOWN REFLEX

Delivery of Placenta → Drop in Progesterone → APG (Anterior Suck → PPG (Posterior Pituitary Gland) → Oxytocin → Lactiferous
Pituitary Gland) → Prolactin → Acini Cells → Milk Production Duct → Milk Injection
 If Breast Engorgement occur, breastmilk the baby to prevent.
 Warm compress for flow
 During breastfeeding = uterine discomfort
BREASTMILK

COLOSTRUM 1st milk 4th month of pregnancy until Day 4 of Postpartum

TRANSITIONAL MILK Day 4 to Day 10
MATURE MILK Day 10 and above
a. FORE MILK a. Constant forming milk, increase in H2O content
b. HIND MILK b. Milk produced after 10 minutes of Breastfeeding, increase
in calories and fats
 Best Schedule for Breastfeeding is According to Babies Demand
 Hunger Behaviors:
o Opening of the Mouth
o Hand Fisted
o Tensed body
o Crying – a late sign of hunger
 Satiety Behaviors:
o Relaxed body
o Withdraws mouth from the nipple
o Falls asleep
o Easily distracted by the environment
 Calories in the Newborn = 50 – 55 kcal/lb./day
 Water requirements are high = 67 – 73 mL/lb./day
o Don’t recommend mixed feeding (breastfeeding + bottle feeding)

ADVANTAGES OF BREASTFEEDING
 First perfect food
 Laxative effects
 With IgA
 Reduces ovarian and breast cancer
 Lactation Amenorrhea Method (LAM) for 6 months
 Fewer Allergies
 Decrease infant morbidity
 o Lactoferrin – Iron-binding protein that interferes growth of bacteria
o Interferon – Protection from virus (protein)
o Lactobacillus-Bifidus – interferes the colonization of the bacteria reducing the incidences of diarrhea
 Brain Development
o Because of the high lactose content
 Rapid Involution
o Because of Oxytocin
 Has Calcium – helps prevent tetany
 Enhances bonding
 Reduces Type 2 Diabetes Mellitus (weight loss)
 Decrease postpartum blood loss
 Economical
 Protection from GI and Respiratory Infections
 Protects baby from otitis media, meningitis, and sepsis
 Early breastfeeding babies, protein metabolism produces less nitrogen wastes.
 Premature babies derived more benefits from breastfeeding
 Breastmilk has Linoleic Acid for skin integrity
NOTE:
 The level of protein in cow’s milk is greater than in human milk, is poorly absorbed and can cause GI bleeding.
 Cow’s milk has higher level of Calcium, Phosphorus, Sodium, and Protein which increase the renal solute load and result in greater
obligatory water loss.
 Delaying breastfeeding can increase risk of death.
BREASTFEEDING HOLD
 Cradle – classic, best for term babies delivered via NSD
 Cross-cradle – best for preterm babies delivered via NSD
 Football/Clutch – best for babies delivered via CS
 Side lying – for mother recovering from a difficult delivery
 Koala – most intimate breastfeeding hold
BURPING HOLD
 Burping Hold – Shoulder Hold
 Burp the baby, middle and end of Feeding
o The more you empty the milk, the more replenish
 Transfer hold, neck to buttocks
 Is Breast Engorgement a contraindication to breastfeeding? NO
 Is Mastitis a contraindication to breastfeeding? NO
o Whatever the cause of Mastitis because the baby’s digestion will kill the bacteria.
 Care of the Breast, no soap, seek care if temperature is 38 degrees Celsius + breast with reddened areas.
VITAL SIGNS

TEMPERATURE 36.5 to 37.5 degree Celsius

HEART RATE 120 – 160 bpm
RESPIRATORY RATE 30 – 60 breaths per minute
BLOOD PRESSURE 60 – 80 systolic
40 – 60 diastolic
 For checking temperature of the baby, we check at Axilla or Tympanic (ear)
o Not in Rectum because it will damage Rectum mucosa
 Heart Rate:
o Sleeping: 100
o Crying: 160
o By the end of infancy, the normal heart rate: 100 – 120 bpm
o Checking Heart Rate at Apex
 Blood Pressure
o We don’t routine check BP until the Age of 3 years old.
o WE don’t routinely check BP unless the baby has heart defect.
 In younger child, check Vital Signs (Rule):
o No touch, first
o Discomfort related, last
o Sequence: RR, PR, Temperature, BP
o In a sick child, proceed from least intrusive to most intrusive
o Observation before manipulation
 o Distract the baby by giving a toy
o Establish rapport and involve parents
o Continue the assessment of neonatal reflex during 1st 6 months of infancy

GENERAL MEASUREMENTS
Less than 2500g = Low Birth Weight (LBW)
Less than 1500g = Very Low Birth Weight (VLBW)
Greater than 4000g = Large Gestational Age (LGA)
 Normal Birth Weight = 2.5 kg – 4kg (2500 – 4000g)
o Birth Weight x 2 = 6 months (Exception: Formula fed babies, Birth weight doubles in 3 – 4 months)
o Birth Weight x 3 = 1 year
o Birth Weight x 4 = 2 years

PHYSIOLOGICAL WEIGHT LOSS

 Loss of 5 – 10% during the 1st week of life
 Due to loss of meconium stools can be regained in the following week.
 Failure of Newborn to regain the weight loss = is a sign of Cystic Fibrosis
o Diet of Patient with Cystic Fibrosis: Low Fat

BIRTH LENGTH
 Normal Birth Weight = 47.5 cm – 52 cm (Average = 50)
o Birth Length + 50% = 1 year old
o Birth Length x 2 = 4 years old
o Birth Length x 3 = 13 years old
 9 – 10 = same height (boys and girls)
 11 years old = girls are taller than boys
 Head Circumference = 33 – 35 cm
o Land Mark: Just above the eyebrows
o Because of molding, it will decrease 0.5. It will return to normal within 2 – 3 days
 Chest Circumference = 31 – 33 cm
o Land Mark: Midline the Nipple
o Pulmonary problem if the chest is larger than the head
o At birth, the head is larger
o At 10 – 12 months, the head and chest are equal
o At 2 years old, the chest is larger than the head
 Abdominal Circumference = 31 – 33 cm
o Land Mark: Umbilical

DENTAL AGE
 Signs of Teething
o Drooling, Resistance to chew, Irritability, Disrupted sleep
 Never Normal Signs
o Earache, convulsion, vomiting, diarrhea, fever
 Teething Discomfort Management:
o Acetaminophen (Tylenol) 10 – 15 mg/kg every 4 hours
o Cold teething rings
o NOTE: An infant who is teething will place almost any object in the mouth.
5 – 6 months Lower Central Incisors
7 – 8 months Upper Central Incisors
9 – 10 months Upper Lateral Incisors
11 – 12 months Lowe Lateral Incisors
12 – 16 months 4 Anterior Molars
16 – 20 months 4 Canines
20 – 30 months 4 Posterior Molars

o The baby will have 8 teeth on his/her 1st birthday

o 2 and half years old, Complete Primary Teeth (Milk Teeth or Temporary)
 Bring the child to the dentist.
o What is the importance of Primary Teeth?
 Essential in protecting the growth of dental arch.
o 6 years’ old = 4 first molars (foundation of dental arch)
 o 7 – 9 years old = 8 incisors
o 10 – 11 years old = 8 bicuspids
o 11 – 12 years old = 4 canines
o 13 years old = 4 second molars
o 17 – 22 years old = 4 third molars
o Permanent Teeth = 32 Teeth
o Pre-schooler = 20 and no new teeth

FOOD INTRODUCTION
5 – 6 months Breakfast and Dinner: Cereals, Rice (Hypoallergenic)
7 months Lunch: Vegetables
8 months Fruits
9 months Meat (Red meats before White meats)
10 months Egg (Egg Yolks first)
 We introduce meals at 5 months
because the extrusion will disappear at 4 months
 The first meals that we need to introduce is Iron-Fortified Foods like Cereals
o Fetus to Newborn has enough Iron Storage
o Babies delivered more than 1 month early, start Iron Supplements at 6 weeks, daily, until 6 months
o Babies delivered more than 2 months early, starts Iron Supplements at 2 weeks, daily, until 6 months
o Milk is not a good source of Iron
 Vegetables are higher in Iron than Fruits
 4 – 7 days before switching the foods to prevent Allergies
 Infants has difficulty digesting fats during the 1st year of life
 Egg yolks are higher Iron than egg whites
 In terms of Boiled Eggs, Hard Boiled is much preferred than Soft Boiled (risk in salmonella)
 After 10 months, we can introduce fish.
 If allergies runs in the family, eliminate the allergic foods.
CHARACTERISTICS OF THE NORMAL NEWBORN
A. HEAD
a. Round and Symmetrical (Cone-shaped head due to molding)
b. Fontanels – Characteristics of Fontanels: Soft to touch, flat, and patent (for brain growth)
i. Posterior Fontanel (Lambda) – Triangle (smaller), closes 2 – 3 months
ii. Anterior Fontanel (Bregma) – Diamond (bigger), closes are 12 – 18 months
iii. If the fontanels close early, REPORT! It indicates Craniosynostosis (closure of the fontanels and suture lines in
advance)
iv. If fontanels are depressed or sunken, dehydration
v. If the fontanels are bulging and the baby is crying – normal
vi. If the fontanels are bulging and the baby is asleep or quiet – Increase ICP
c. By 4 months head control

CAPUT SUCCEDANEUM CEPHALHEMATOMA

Scalp Edema Collection of blood
Present at birth Present 12 – 24 hours after delivery
Disappears in few days Reabsorbs in few weeks
Bilateral Unilateral
Crosses suture lines Doesn’t cross suture lines
Due to pressure of soft pelvis Due to pressure of hard pelvis, forceps
Soft to touch Firm to touch
B. FACE
a. Eyes – real color at 3 months, strabismus, tearless
i. Poor Neuromuscular
1. Increase Control should be straight by 3 months
2. Poor lacrimal Structures (by 2 months = with tears)
b. Vision – can see 8 – 10 inches
c. Subconjunctival Hemorrhage – NORMAL
i. Red spots to the sclera are normal related to birth crosses
d. Ears
i. Low set of ears – Trisomy 21
ii. Flat and shapeless – Preterm
e. Hearing – can elicit Moro Reflex
f. Nose – sensitive to breastmilk sneezing present at birth
g. Mouth – lips are equal and Epstein pearls (normal)
 i. Abnormal: Oral Thrush = Moniliasis
ii. Causes of Oral Thrush = Candida Albicans
iii. Fetal Alcohol Syndrome Characteristics: Microcephaly, Flat and Upturned Nose, Small Eyes, Thin Upper Lip, Big
Ears.
C. NECK
a. Moves freely, nonpalpable thyroid
D. CHEST
a. Coughing reflex, Witch’s milk, Clavicle is intact,
b. Large baby: Broken clavicle
E. ABDOMEN
a. Kidneys, liver, and spleen are normally palpable
b. OMPHALANGIA – is cord bleeding
i. Most common site of Hemophilia to Newborn
ii. Hemophilia is a clotting factor deficient
iii. Hemarthrosis – is a bleeding into a joint space
c. FOUL DRAINAGE
i. Indicates Infection
F. GENITALIA
a. MALE GENITALIA
i. Phimosis – is a tight foreskin (normal until the age of 3)
1. If it interferes in voiding, surgery (circumcision)
ii. Epispadias – urethral opening at dorsal segment
1. Only needed surgery if the case is severe like no urethra
2. Surgery before school entry to allow penile growth
iii. Hypospadias – urethral opening at ventral segment
iv. Cryptorchidism – undescended testes
1. Characteristics of Preterm baby
2. Surgery: Orchiopexy (but not during the 1st year – if done within a year a testes will spontaneously
descend)
3. Cryptorchidism will lead to sterility and testicular cancer.
b. FEMAL GENITALIA
i. Hymen is intact and evident
ii. Clitoris is enlarged – labia may be edematous
iii. Pseudomenstruation – is NORMAL due to exposure to maternal hormones
G. BACK
a. Flat and straight is NORMAL. Within sac or dimple or with tuft of hair SPINA BIFIDA
H. BUTTOCKS
a. Mongolian Spots – common to newborn with dark complexion
I. ANUS
a. The presence of meconium stool confirms anal patency
J. EXTREMITIES
a. Talipes Equinovarus – clubfoot (bootleg cast for 4 – 6 weeks)
i. Common to male
ii. Bootleg is changed every 2 weeks because of the rapid growth of the child
b. Amelia – absence of limbs due to Thalidomide (Anti-Emetic)
c. Phocomelia – absence of distal limbs or shortened limbs due to Thalidomide (Anti-Emetic)
d. Congenital Hip Dysplasia – (hip spica cast for 6 – 9 months)
i. Common to female, breech presentation, oligohydramnios
ii. Asymmetrical Gluteal Folds, Popliteal Lines, Ankle Lines
iii. Positive Ortolani’s Sign (Clicking)
e. Polydactyly – Extra finger/toe (common at foot)
f. Syndactyly – Webbed
g. Adactyly – Absence of finger/toe
K. SKIN
a. Skin Colors
i. Pinkish – Well perfused
ii. Bluish – Cyanosis
iii. Greenish – Meconium Stained
1. Common at post-term
iv. Reddish – Elevated Hematocrit
v. Yellowish – Jaundice
1. Pathologic – 1st 24 hours caused by Hemolytic Disease of Fetus
2. Physiologic – 2 – 3rd day of 7th day caused by immature liver
vi. NOTE: Fetal RBCs are elevated, at birth there is a destruction of RBCs (hemolysis) leading to Indirect Bilirubin
and it is converted (Liver Enzymes Glucoronyl Transferase) leading to Direct Bilirubin and excreted from the body
b. Skin Rashes/Marks/Signs
 i. Milia – white pinpoint papules on the nose, cheeks, chin, and forehead
1. Caused by immature spaceous glands
2. Disappears in 2 – 4 weeks
ii. Lanugo – fine downy hair it covers the shoulder, back, and upper arms
1. Many Lanugos in Preterm babies
2. It disappears gradually in 2 weeks
iii. Vernix Caseosa – whitish and cheesy
1. More Vernix Caseosa = Preterm
2. Few Vernix Caseosa = post-term
3. It serves as thermoregulation and lubricant
4. If the Vernix is yellow, bilirubin
5. If the Vernix is green, meconium
iv. Mongolian Spots – grayish blue patch over the buttocks
v. Newborn Rash – pink or white papule rash (erythema toxicum neotorum)
1. Appears up to 2 weeks
2. Due to Eosinophils
3. IT is harmless, requires no treatment
vi. Nevi – Stork bites
1. Pinkish discoloration in the eyelids, lips
2. Common at newborn with light complexion
vii. Bruising
1. In the equipment
viii. Desquamation – dry peeling of the skin
1. Normal at the soles
2. At the entire body = post-term
3. Placenta starts degeneration at 26 weeks and the fetus will not get enough nutrition so that the fetus will
become malnourish
ix. Harlequin Sign – the lower dependent portion of the body is darker in shades than he upper independent portion
1. Caused by sluggish peripheral circulation
REFLEXES IN THE NEWBORN
 Rooting – turns the head to direction of stimulus, disappears by 6 weeks
 Sucking – anything that touches her lips is sucked, disappears by 6 months
 Swallowing – anything that touches the posterior tongue
 Extrusion (Sitting-up/expelled) – anything that touches the anterior tongue, disappears by 3 – 4 months
PROTECTIVE REFLEXES (LIFETIME)
 Blinking – protecting the eyes
 Sneezing – protecting the nose
 Yawning – to protect cells from depleted oxygen
 Gagging – to prevent aspirations
 Moro Reflex – seen as embracing motion of the arms, abduction followed by adduction of the arms and legs spread away.
o Disappears by the End of 4 – 5 months
o Other Term: Startle Reflex
o Most significant index of CNS
o Absence means brain damage/CNS problem
 Parachute Reflex (develops at 6 – 9 months) – when in prone position and the examining table is suddenly lowered, arms extend to
protect self.
 NOTE: If the child has hemiplegia, the response in only noticeable on the unaffected side.
 Babinski Reflex – fanning of toes when the sole is stroked from the heels upward due to immaturity of nervous system
o Most acute on the first month and gradually disappears until 12 months
 Tonic Neck – When on supine, infants turns his head to one side and arms and legs in the side to which the head turns extend
and opposite arm and leg flex. Disappears on 2 – 3 months.
 Darwinian – Demonstration of a quick few steps when the newborn is held in a vertical position and feet touch a hard surface.
Disappears in 3- 4 months. Other terms: step-in place/walk/dancing
 Palmar – Grasps on examiners finger when palm is stimulated. Disappears at 6 weeks to 3 months
 Plantar – tendency to curl toes inward when the sole of the foot stimulated. Lessen after 8 – 9 months in preparation for walking.
 Landau – when held in prone with hand underneath him supporting his trunk, the body demonstrate some muscle tone and keeps his
head in line with the trunk. Develops at 3 months
 NOTE: Sagging into inverted “U” position indicates poor muscle tone
3 REFLEXES USED AS TESTS OF SPINAL CORD
1. MAGNET – if pressure is applied to the soles of the feet of an infant lying in supine position THE NEWBORN WILL PUSH AGAINST
THE PRESSURE.
 2. CROSSED EXTENSION – If one leg of newborn lying supine is extended and the soles of the foot is irritated by rubbing it with sharp
object-like thumbs, HE WILL RAISE THE OTHER LEG, CROSS IT and try to push away the hands irritating the first leg.
3. TRUNK INCURVATION or GALANT – when the newborn is in prone position and is touched along the paravertebral area by a
probing finger, he will FLEX HIS TRUNK AND SWING his pelvis to the side.
CHARACTERISTICS OF PRETERM BABY
Less than 37 weeks
 Small  Only partial flexion of the lower extremities
 Large head  Poor sucking
 Less around  Soft nails
 Lots of Lanugo  Undescended testes or very high in the inguinal canal
 Low body temperature (due to low subcutaneous fats  Small scrotum
deposition)  Blood vessels readily apparent
 Labored breathing (low/decrease surfactant)  Thin, transparent wrinkled skin
 Lack of reflexes  Small areola or barely visible
 Weak cry  Ear is flat/shapeless
 Flaccid/limp/floppy  Smooth sole of the feet (very few or no creases)
CHARACTERISTICS OF POSTTERM
 Dry skin – due to fetal malnutrition
 Desquamation skin – due to fetal malnutrition
 Long nails
 Absent lanugo
 Deep creases on the baby’s palm and soles of the feet
 Abundant scalp hair
 Brown, green skin – due to meconium staining
o NOTE: Fetal hypoxia due to PLACENTAL INSUFFICIENCY stimulates the Vagus Nerve leading to relaxation of the Canal
Sphincter and increase in peristalsis then the meconium will release leading to staining
o NOTE: The placenta will start to degenerate at 36 weeks.
 Polycythemia – compensatory mechanism due to lack of oxygen, lack of RBC
 Wide eyed
 Placental Insufficiency
 Green skin
 Meconium Staining
PROMOTING INFANT DEVELOPMENT IN DAILY ACTIVITIES
 Bathing
o An infant does not need a bath everyday – To prevent skin drying
 Temperature of Water: 37 – 38 degrees Celsius
o An infant does not need their head and scalp washed frequently
 Scaly scalp called Seborrhea
o Do not leave infants alone in tubs
o After bathing, avoid talcum powder because it is allergenic
o Wash the face of the infant using water only.
 Diaper-area Care
o Change frequently every 2 – 4 hours
o At each diaper change, wash the skin with clear water or with a commercial alcohol-free diaper wipe
o Petroleum jelly maybe applied after cleaning
o Pseudomenstruation is normal – pinkish discharge on baby
 Care of the Teeth
o Exposed developing teeth to fluoride
o The most important time for children to receive fluoride is between 6 months and 12 years of age
o Begin brushing even before teeth erupt by rubbing a soft washcloth over the gum pads to eliminate plaques and reduce
bacteria.
o Once teeth erupt, brush once or twice daily
o Toothpaste is not necessary for an infant, because it is the scrubbing that removes the plaque
o The initial dental check-up should be made by 2 – 2.5 years of age (first dental check-up) at 6-month interval
 NOTE: The first dental check-up is 2 – 2.5 years of age or Primary Teeth is complete
 Dressing
o Should be easy to launder and simply constructed
o Clothing should not be binding
o Needs soft soled shoes
 Sleep
 o Infants require 10 – 12 hours of sleep at night and one or several nap during the day
 Infants: 10 – 12 hours
 Newborn: for an average of 16 hours during the 1st week
 Newborns wakes up every 4 – 5 hours for the needs of fluid
 4 months: around 15 hours
o Caution parents not to place pillows in an infant’s bed to avoid suffocation
o Always PLACE INFANT ON HIS/HER BACK TO SLEEP to reduce the incidence of Sudden Infant Death Syndrome (SIDS)
 Exposure to Sun
o Exposing for only 3 – 5 minutes the first day and so up to 15 – 20 minutes at a time
o Sunscreen is not recommended until they are 6 months old
 Thumbsucking
o Infants begin to suck a thumb about 3 months of age and continue the habit through the first few years of life
o Assure parents that thumb-sucking is normal and does not deform the jawline as long as it stops by school-age.
o Thumbsucking satisfy the oral needs of the infants.

PRINCIPLES OF GRWITH AND DEVELOPMENT

1. Continuous Process
2. Orderly Sequence
3. Predictable Stages
4. Cephalocaudal
5. Proximal to Distal (Center to Peripheries)
6. Gross to refined skills
7. Reflexes must be lost before development
8. Learned by Practice
a. NOTE: The Development is Qualitative, Growth is Quantitative
b. NOTE: Development/Maturation, Growth stops while Development stays or Improve
DEVELOPMENTAL MILESTOENS
 1st Month
o Complete head lags
o Lifts head for short periods
o Follows moving objects into midline vision
o Smiles indiscriminately
o Holding baby from head to buttocks
 2nd Month
o Holds head up when in prone
o Social Smile (Emotional Development)
o Cries with tears
o Cooing Sound (dovelike)
o Head lag when pulled to sitting position
o No longer clinches fist tightly
o Follows object past midline
o Recognizes parents
o Holds rattle briefly
o Rolls from side to back
 3rd Month
o Reaches for familiar people or objects
o Anticipates feeding
o Starts to drool
o Hold head erect and steady when held in sitting position
o Can gold head but not chest when prone
o Follows moving objects 180 degrees
o Hand regard (play) – they hold their fingers in front of their faces
 NOTE: Play of Infant is Solitary Play
 4th Month
o Head Control Complete – ***BON QUESTION
o Can raise head and chest up when prone
o Turns fronts and back; needs space to turn (play)
o Rolls from back to side
o Laughs aloud; Babbling Sounds
o Thumb Opposition – the ability if the child to bring thumbs and fingers together
 5th Month
 o Turn both ways (roll over) = in the other books 6 months
o Handles Rattles Well (best toy) ***BON QUESTION
o Enjoys looking around environment
o Takes objects presented to him (and grasps with the whole hand)
o NOTE: Fisting that persist beyond 5 months suggest a delay in motor development.
 6th Month
o Reaches out in the anticipation of being picked-up
o Sits with Support ***BON QUESTION
o Puts feet in mouth in supine position
o Vowels sounds “ah and eh”
o Uses palmar grasp
o Handle Bottle Well (weaning age from breast bottle) ***BON QUESTION
 Allowing the baby with bottle of milk, fruit juices, or anything sweet during bedtime leads to Baby Bottle Syndrome
(Tooth Decay of the Upper Teeth)
 Allowed bottle of water
o Recognize strangers ***BON QUESTION
o Smiles at self in the mirror
 7th Month
o Sits for short period without support ***BON QUESTION
o Transfer objects from hand to hand (6 – 7 months)
o Likes the objects that are good sized for transferring
 8th Month
o Sites without support ***BON QUESTION
o Peak of Stranger Anxiety ***BON QUESTION
o Begins to Follow Simple Commands like Wave Bye-Bye ***BON QUESTION
 9th Month
o Creeps od crawls; need space for creeping
o Neat Pincer Grasp Reflex (in other books 10 months) probes with forefinger SAFETY ALERT – No Small Toys
o Finger feeds
o Combine 2 syllables “mama and dada” (9 – 10 months). FIRST WORD: Dada (because it is easier to said)
o Infants are very aware of the changes in tone of voice
 10th Month
o Pulls self to stand
o Understand the word no
o Infant masters another word such as “bye-bye” or “no”
o Respond to name
o Peek-a-boo (Example of Object Permanence Development) ***BON QUESTION
 Less than 10 months, gone is gone to the baby
o Pat a cake, since they can clap
 11th Month
o Cruising
o Stand with assistance
o Walking while holding to his crib’s handle
o One word other than mama and dada
 12th Month
o Stands Alone ***BON QUESTION
o Walk with assistance
o Drink from cup (other books 10 months)
o Cooperates in dressing
o Says two words other than mama and dada
o Pots and pans, pull toys and nursery rhymes (they like to play interactively)
o Imitates actions, comes when called
o Follows one-step command and gesture
o Uses mature pincer grasp, throws objects
o Knows own name
o Vocalize 4 – 5 words
o Most children have overcome their fear of strangers
 Alert and responsive again when they are approached.
LANGUAGE DEVELOPMENT DURING THE FIRST YEARS
 Differentiating a cry (2 months)
 Squeal with pleasure, in response to a nodding , smiling face (3 months)
 Infants are very talkative, babbling and gargling, laughs out loud when spoken to 4 months
 Simple vowel sounds (oh-oh) (5 – 6 months)
 Combine 2 syllables “dada” = FIRST WORD (9 – 10 months)
 Saying two words (10 – 12 months)

 15th Month
o Walks Alone
o Puts small pellets into small bottle
o Creep upstairs
o 4 – 6 words
o Scribbles voluntarily with pencil
o Holds spoon well (in other books 12 months)
o Seat self in a chair
o NOTE: In selecting a Toy:
 Safety
 Age Appropriateness
 Usefulness
 18th Month
o Height of Possessiveness – favorite word; MINE/NO
o TOILET TRAINING BEGINS
 Prerequisite: Physiologic Readiness
 She/he knows the meaning of Sphincter Control (when there is an urgency to defecate, he/she will says it)
 The most common in delay in Toilet Training is starting too early.
 Principles of Toilet Training:
 Firm
 Consistent
 Positive Maternal Attitude
 Strict Toilet Training will result in Obsessive Compulsive in Children.
 Poor Toilet Training will lead to stubborn, unorganized attitude of Children
 NOTE: Bowel Training before Bladder Training
 Bowel Training - 18 – 24 months
 Bladder Training - 24 – 30 months daytime
 Bladder Training - 30 – 36 months nighttime
o No longer rotates a spoon
o Can run and jump in place
o Walks up and downstairs holding on to a person’s hand or railing, typically places both feet on one step before advancing
o Names one body part
 24th Month
o Turns pages one at a time, removes shoes, pants, etc.
o Can open doors by door knobs, unscrew lids
o 50 – 200 words (2-word sentences), knows 5 body parts
o Walk upstairs alone, still using feet on the same step at same time
 30th Month
o Makes simple lines or stroke or crosses with pencil
o Can jump down from chair
o Knows full name, holds up finger to show age
 3 years-old
o TRUSTING THREES
o Tooth brushing with little supervision
o Unbutton buttons
o Draws a cross, learns how to shares
 Cross and Circle Shapes – 3 years-old
 Square Shape – 4 years-old
 Triangle Shape – 5 years-old
 Diamond Shape – 6 - 7 years-old
o Speaks fluently; 200 – 900 words
o Rides Tricycles
o Copies circle
o With 900-word vocabulary
o Undress without help
o Jumps off one step
o Walks backward
o Walks upstairs alternating feet and walk downstairs without assistance 1 foot at a time
 4 Years-old
o Furious
o Doubles birth length
o Hops on one foot ***BON QUESTION
o Climbs and jumps well
o Walk downstairs alternating feet
o Skips and hops on one foot
o Throws ball overhead
o Copies Square
o Dresses self with assistance
o Laces shoes ***BON QUESTION
o Brushes teeth and bathes self
o Peak of aggressiveness and impatience
o HAS A 1500-WORD VOCUBALARY, commonly stutters (4th – 5th years)
o Counts 1 to 5
o With a 20-minute attention span
o Says songs or poems from memory
o Knows basic colors
 5 years-old
o Runs well
o Jumps rope
o Copies triangle
o Skips and hops on ALTERNATE FEET
o Balances on one foot
o Throws and catches a ball
o Dresses completely without help ***BON QUESTION
o Eager to please
o Takes increase responsibility for actions
o Names 4 or more colors
o Has 2000 – 2100-word vocabulary
o Knows name and address
o Counts to 10
o With 30-minute attention span
 6 years-old
o Starts to ride a bicycle
o Ties knot
o Shows extreme sensitivity to criticism
 7 years-old
o Rides bicycle well
o Increase self-reliance for basic activities
o Engages in active games
o Joins Organization
o Draws a person with 16 parts
 8 years-old
o EYE DEVELOPMENT GENERALLY COMPLETE
o Movements more graceful
 9 – 10 years-old
o Normal 20/20 vision
o Has well developed eye-hand coordination
o Better behaved
o Likes schools
o Enjoys team’s sports
o Boys and Girls same size (age 9)
o Enjoys reading books
o Enjoy collecting things
 11 – 12 years-old
o Awkward because of growth spurt
o Attains 90% of facial growth
o Helps others, increasingly responsible
o More selective in choosing friends, has best friends, loyal to friends, enjoys peer activities
o Develops beginning interest in the opposite sex, boys tease girls, girls flirt with boys
o Girls bigger than boys (11-12 years old)
COMPARISONS ACROSS THE PEDIATRIC AGE

AGE GROUPS SIGNIFICANT PERSON PLAY FEAR

Infants Mother, Father and Primary Care Provider Solitary Play Stranger Anxiety
(0 – 1 year)
Toddler Parents or toddler himself Parallel Play Separation Anxiety
(2 – 5 years)
Pre-schooler Basic Family Associative/Cooperative Body Mutilation/Castration
(2 – 5 years) (beginning of sibling rivalry)
Schooler Teachers and Classmate Competitive (with rules) Lack of Belongingness/Death
(6 – 12 years)
Adolescent Peers Social Loss of Control/Body Image
(13 and above) Disturbance/Death

o Stages of Separation Anxiety:

 Protest – absences of protest to a child means child abuse (need further investigation)
 Despair
 Denial

TOODLER PRESCHOOLER SCHOOLER

Negativistic Magical Thinking Classifying, Sorting, Collecting
Rigid, Ritualistic (allow to gain mastery) Imaginary Friends Confidence Building
Egocentrism (selfishness) Telling Tales Love to Win
No Sharing Sharing Difficulty Learning how to do things well
Temper Tantrums Family Romance Boy-Boy, Girl-Girl Relationship
Timeout Sibling Rivalry
Toilet Training Imitative
 NOTES:
o Management of Temper Tantrums: Ignore the Behavior but make sure the child is safe.
o Disciplinary starts at Toddlerhood using TIMEOUT
 TIMEOUT is One-Minute per Age, give clear instruction
o Toddlers don’t follow commands other than his/her parents.
o Telling Tales – Stretching the stories
o Types of Family Romance:
 Oedipal – The Son shows attachment to Mother but shows jealousy to the Father.
 Electra – The Daughter attachment to Father but shows jealousy to the Mother.
 Management: Identification – you will make your child understand your role to the family.

TOODLER PRESCHOOLER SCHOOLER

BP NOT ROUTINELY CHECKED BP = 100/60 BP = 112/60
PR = 90 – 110 PR = 85 PR = 70 – 80
1300 – 1400 Calorie per Day 1700 – 1800 Calorie per Day 2100 Calorie per Day
Physiologic Anorexia No New Teeth Brain Growth Complete – 10 years of Age
Pouchy Abdomen Fears Dark, Mutilation and Abandonment
Speaks in Two-word sentences Vocabulary Increase Markedly Talks in Full Sentences
Lordosis Body Contour Changes Posture becomes more Erect
 NOTES:
o Universal Fear of Children = DARK

THEORIES OF DEVELOPMENT
Jean Piaget’s Cognitive Development (4 Categories)
1. SENSORIMOTOR
a. Use of reflexes – birth to one month (infant mainly uses simple reflex activity.)
b. Primary Circular Reaction – infants explore objects by grasping them with hands or by mouthing them (1 – 4 months)
i. Unaware of Action
c. Secondary Circulation Reaction – differentiate self from 4 – 8 months, they can grasp the idea their actions can initiate
pleasurable sensation.
i. Aware of Actions
d. Coordination of Secondary Schema – discovers object permanence (10 months/8 – 12 months)
e. Tertiary Circular Reaction – Little scientists 12 – 18 months (Toddler)
f. Intervention of New Means – able to try out various actions mentally remember action and imitate it later 18 months – 2
years old
2. PREOPERATIONAL (2 – 7 years’ old)
a. Preconceptual – egocentrism (2 – 4 years old)
b. Intuitive Thoughts (4 – 7 years old) – diminishing egocentrism
c. Centration – focus to one task at a time
 d. Classifies objects by single frame
e. Assimilation – they learn to change the situation on how they perceive it.
f. Preoperational mainly for preschooler
3. CONCRETE OPERATIONAL (7 – 12 years old)
a. Classification and sorting
b. Seriation – groups object
i. There is no Seriation without Assimilation
c. Conservation – understanding that values remain the same, ability to appreciate that a shape does not mean a change in
size. Constancy despite Transformation
d. Reversibility
e. Decentration – can focus more than one thing at a time
f. Inductive Reasoning – exposure to different viewpoints
g. Accommodation – ability to adapt through processes to fit what is perceived
h. Concrete Operation is mainly for Schooler.
4. FORMAL OPERATIONAL (12 years and above)
a. Abstract Thinking
b. Logical and Rational Thinking
c. Futuristics Thinking
d. Deductive Reasoning (General to Specific)
e. Hypothetical Thinking (Scientific Reasoning)
i. Cognition = Final Form
ii. Best Activity = Talk Time
f. Formal Operational mainly for Adolescent
SIGMUND FREUD’S PSYCHOSEXUAL THEORY

PHASE AGE SITE OF GRATIFICATION ACTIVITIES

Biting, Crying, Sucking,
ORAL 0 – 18 months Mouth (Enjoyment and release of
tension), Thumbsucking
ANAL 19 months – 3 years Anus Elimination Retention/Defecation
PHALLIC 4 – 6 years Genital May show exhibitionism. Have or
increase knowledge of 2 sexes
Period of suppression
No obvious development, slower
LATENCY 7 – 12 years School-age growth.
Child’s energy or Libido is
diverted into more concrete type
of thinking.
Achieve sexual maturity and
GENITAL 12 – 18 years Genitalia learns to establish satisfactory
relationship with the opposite
sex
 NOTE:
o Phallic Phase
 Fondling of his/her Genitalia = EXPLORATION (NORMAL)
 If child, when masturbating diverts or distract the child
 If Adolescent, provide privacy
 Answer questions directly, as simple as you can.
o Latent Phase
 Help a child achieve positive experiences.
o Genital
 Give opportunity regarding to relationship
o Fixation = persistent focus to earlier psychosexual task.

ERIK ERICKSON’S STAGES OF PSYCHOSOCIAL THEORY

Trust vs. Distrust Ability to trust other and meets the needs consistently.
(Security)
Autonomy vs. Shame vs. Doubt Self-control, will, courage
(independence and self-governance)
Initiative vs. Guilt Ability to assert, initiate activities (experiences)
(Basic Things)
Industry vs. Inferiority Ability to persevere, leading to a sense of competence
(Do things well)
Identity vs. Role Confusion Coherent sense of self

 NOTE:
 o Trust is the Foundation of All Psychosocial Task.
 To build the trust of the infant/children care with consistency

KOHLBERG’S THEORY OF MORAL DEVELOPMENT

AGE STAGE DESCRIPTION

INFANCY 0 INFANCY NO CONCEPT OF RULES TO OBEY
PRECONVENTIONAL (LEVEL I)
2 – 3 years 1 PUNISHMENT/OBIDIENCE/ORIENTATION
(TODDLER) Give Clear Instruction
OBEY AND AVOID PUNISHMENT
2 – 7 years 2 Individual Relativism
(PRESCHOOLER) Give and Take (exchange)
CONVENTIONAL (LEVEL II)
7 – 10 years 3 ORIENTATION TO INTERPERSONAL RELATIONS OF MUTUALITY
Good Boy/Good Girl
10 – 12 years 4 MAINTENANCE OF SOCIAL ORDER,FIXED RULES AND
AUTHORITY
Follows Rules of Society
POST-CONVENTIONAL (LEVEL III)
5 SOCIAL CONTRACT
Follows Standards of Society (Utilitarianism)
OLDER THAN 12 6 UNIVERSAL ETHICAL PRICIPLE ORIENTATION
Ideal Stage of Moral Development
20% of Adult Population

GASTROINTESTINAL SYSTEM
 ESOPHAGEAL ATREISA (TEA)
o Esophagus leads to a blind pouch (most common)
o They have Polyhydramnios
 TRACHEAL-ESOPHAGEAL FISTULA (TEF)
o Abnormal connection
o Opening between the closed esophagus and trachea
o 3 C’s
 Coughing
 Choking
 Cyanosis
 Excessive Drooling
o Infants will go NPO and need Emergency Surgery to prevent Pneumonia
 The infant will have Total Parenteral Nutrition to prevent Hypoglycemia
 NOTES: TEA/TEF must be ruled out to infants born to a woman with POLYHYDRAMNIOS. Mostly PRETERM
o Complications:
 Respiratory Distress
 Aspiration Pneumonia
o Management:
 Total Parenteral Nutrition (TPN) – Oral fluids cannot be given
 Emergency Surgery – closing the fistula and anastomosing the esophageal segment. Done within 24 – 48 hours
 Antibiotics – To help prevent infection
 PYLORIC STENOSIS (NARROWING)
o Hypertrophy of muscle of pylorus
o Exact Cause: Unknown
o Diagnosis: Endoscopy
o Signs and Symptoms:
 Non-bile vomiting, sour vomitus, projectile vomiting (3 – 4 feet)
 Hungry after vomiting but not nauseated
 Signs of Dehydration from vomiting
 Olive shaped mass (Right Upper Quadrant)
 Abdominal Distention
o Management: Surgical Correction (Pyloromyotomy) – to allow larger lumen
  After the electrolyte correction (especially hypoglycemia), the surgery will do
 Feed the child with thickened formula because it is difficult to vomit
 At risk for infection
 CLEFT LIP
o Non-infusion of facial processes.
o Common to males
o Sucking difficulties
o Feeding Position: Upright Position (pre and post-surgery)
o Feeder: Rubber tip/Bulb Syringe or Dropper
o Surgery: 10 weeks, 10 lbs weight (Cheiloplasty)
 Revision at 4 – 6 years, but if the creation is good no need for revision
o Position Post-Surgery: Supine
o Logan Bar – it is an apparatus that will protect the mouth or surgical repair
 Infants undergo Cheiloplasty should not cry because crying will increase tension to the suture line.
 NPO for 4 hours after the surgery then introduce clear fluids
 Keep elbow restraint
 Mother should be aware of the feeding cues or signs of hunger to avoid crying to the baby.
 CLEFT PALATE
o Non-infusion of the tissues and bones of the hard and soft palate.
o More common to Female.
o Swallowing difficulties
o Feeding: Upright Position
o Feeder: Cleft Palate Feeder – closes the roof of the mouth
o Surgery: Palatoplasty or Uranoplasty (DELAYED SURGERY)
 Done at 18 – 24 months (toddlerhood)
 Before the speech training
 During the 1st year of life, the hard and sift palate will fuse that is why is it delayed.
 If the surgery is delayed, soft diet.
 Post-surgery Position: Prone – to prevent aspiration
 Clear Liquids Diet for 3 – 4 days (DO NT GIVE MILK YET UNTIL SUTURES ARE REMOVED – because milkerds
to the sutures)
 After surgery feed the baby USE CUP
 Avoid: No Fork, Tongue Depression, Dropper, Straw, Spoon (small and long)
 CELIAC DISEASE/GLUTEN-INDUCED ENTEROPATHY
o Sensitivity to Gluten found in Grains
 B – Barley
 R – Rye
 O – Oats
 W – Wheat
o Diagnosis: Serum Analysis against Gluten Antigliadin IgA
o Signs and Symptoms:
 Inability to absorb fats
 Malnutrition (due to malabsorption)
 Deficiency in fat soluble vitamins (A, D, E, K)
 Diarrhea and GI irritations – when they consumed gluten products/foods
 Rickets
 Hypoprothrombinemia
 Iron Deficiency Anemia (due to decrease Iron Absorption)
 Hypoalbuminemia
 Fatigue
 Bloating
 Abdominal Pain
 Vomiting
 Steatorrhea – bulky and fatty stool
o Management:
 Gluten-free diet for life
 Food to avoid: pizza, spaghetti, bread, wheat, cookies, pastries, Hotdogs, luncheon meat, starchy products, foods
with gravy, instant soup, noodle, canned soup
 Phenylketonuria (PKU)
o Absence of liver enzyme (Phenylalanine Hydroxylate) it prevents conversion of phenylalanine to tyrosine
o Signs and Symptoms:
 Blonde hair blue eyes and fair skin (due to lack of melanin)
 Musty Odor of Urine (breakdown of Phenylalanine Metabolite: Phenylpyruvic Acid)
 Diarrhea, Anorexia, Anemia, Convulsion (due to decrease of epinephrine)
  Abnormal neurologic development
o Diagnostic Test: Guthie Capillary Blood Test
 Increase protein diet for 2 days prior to screening – breastfeed first
o Management:
 Limit Breastmilk intake
 Detect PKU early – IQ will not be affected
 Lofenalac (Phenylalanine-free direct milk formula)
 For 6 – 8 years to prevent Mental Retardation
 Low Phenylalanine Diet
 Orange juice, banana, potatoes, lettuce, Spinach, peas (vegetable and fruits)
 Avoid: eggs, milk, meat (rich in protein)
 Maintain a low level of Phenylalanine in the blood (3 – 7 mg/100 mL)
 Check hemoglobin regularly to ensure the child is not anemic
 Hirschsprung Disease
o Aganglionic Megacolon
o Absence of parasympathetic nerve ganglion responsible of Peristalsis (lower portion of sigmoid colon just above the anus)
o More common to Males
o Signs and Symptoms:
 No Meconium Stools (newborn)
 Chronic Constipation – due to no peristalsis
 Ribbon like stools
 Abdominal Distention
 Fecal Odor of Breath
o Management:
 2-stage Surgery
 Temporary Colostomy (1 year)
 Bowel Repair (Bowel Resection = 12 – 18 months)
o If anus is deprived with nerve endings after surgery permanent colostomy is established
 Liquid Diet as soon as peristalsis occurs after 24 hours
o Assess bowel sounds/flatus
o Liquid diet then soft diet to low residue until normal diet
 Intussusception
o 6 – 12 months of infancy
o Telescoping (Invagination) of intestines (below the ampulla of vater – where bile flows) leading to Intestinal Obstruction
o Signs:
 Currant Jelly Stools
 Abdominal Pain due to peristaltic wave
 Vomitus contains bile
 Abdominal distention
o Management:
 Prompt Surgery: to straighten the invaginated portion. (before necrosis of invagination portion occurs)
 Instilling water-soluble solution
 Air insufflation
 Observe the child for 24 hours because intussusception may recur
 X-linked Hemophilia
o Clotting factor deficiency (mother to son)
 Clotting Factor VII Deficient (classic)
 Clotting Factor IX Deficient
 Clotting Factor XI Deficient
o Platelet Count is NORMAL
o Prothrombin Time is NORMAL
o Partial Thromboplastin Time – best test to reveal low levels of Factor VIII
o Signs:
 Cord Bleeding
 Nose Bleeding
 Anemia
 Hematuria
 Ecchymosis Patches
 Hemarthrosis (bleeding into a joint space)
o Management:
 Control Bleeding:
 Giving of concentrate of Factor VIII
 Cryoprecipitate
 Fresh Frozen Plasma
  ICCE – Immobilize, cold compress, Elevation
o Immobilize f affected part for 48 hours
o Cold Compression for 10 – 15 minutes
o Elevation of affected part above the heart.
 Desmopressin – to stimulate release of Factor VIII
 Aspirin is contraindicated – blood thinner
 Provide teachings to prevent bleeding
 Sickle-Cell Disease
o RBC sickles when under:
 Low Oxygenation
 Dehydration
 High Altitude
 Cold Weather
o Signs:
 Anemia and fever (initial signs)
 Severe pain
 Severe chronic anemia
 Irritability
 Anorexia
 Jaundice
 Liver Enlargement
o SICKLE CELL CRISIS
 RBC can’t move properly leading to poling in the vessels then creating blockage resulting to tissue hypoxia
leading to vasoocclusive crisis leading to thrombus and resulting to death.
o 3 primary needs:
 Pain Relief (Acetaminophen)
 Rehydration (IV Fluids)
 Oxygenation
 Cystic Fibrosis
o A Pulmonary Disorder
o Pancreatic Enzyme Trypsin is Absent
o Generalized dysfunction of exocrine (mucus-producing gland) leading to excessive secretions leading to obstruction and
Fibrotic changes in various organs
o Diagnostic Test: Sweat Test
 Excessive Sodium (70 mEq/L)
 Excessive Chloride (60 mEq/L)
o Signs:
 Meconium Ileus (hardened Meconium) – due to lack of trypsin
 COPD (Barrel-chest) – thick and tenacious lung secretions
 Celiac Syndrome (Steatorrhea – fatty and bulky) – due to decrease pancreatic enzymes
 Protuberant abdomen
 Poor digestion of fats
 Salty sweats, dehydration, weakness and fatigue
 Sterility/Infertility
 High chance of Heredity if both parents
o Management:
 Long term use of pancreatic enzyme (Viokase, Pancreatin)
 Give with cold food
 Do not crush
 Do not chew
 Antibiotic for infection
 Fat-soluble vitamins given in water miscible form
 Diet: Increase protein, calories, vitamins, minerals, sodium
 Decrease fat
 Avoid excessive sweating